Ask The Forum

Formula fed infants should also begin a supplement from birth. When they are drinking more than 800mLs a day, they do not need the supplement as all formula milks are fortified with vitamin D.

Advice on vitamin D supplementation needs to be given opportunistically as not all infants or toddlers are monitored regularly. We suggest advice on vitamin D supplementation for children should be given to mothers before the birth or soon afterwards.

Healthcare professionals should recommend a daily supplement containing:

– 8.5 -10µg vitamin D vitamin D for infants

– 10µg vitamin D for all toddlers, pregnant and breastfeeding women

Most vitamin D is made in the skin when toddlers are outside during the summer months i.e. April – September in the UK. It is the ultraviolet sunlight which acts on exposed skin to make vitamin D.

Babies and toddlers who are deficient in vitamin D may develop rickets or bone deformities. More rarely, vitamin D deficiency can cause fits and tetany in babies. Toddlers of African, African-Caribbean and South Asian origin may be at risk of vitamin D deficiency because darker skin pigmentation means that less vitamin D is synthesised in sunlight.

Very few foods provide vitamin D – in the best food source is oily fish. Formula milks, and some breakfast cereals, breads and yogurts are enriched with it.

Toddlers need 10µg (400 IUs) of vitamin D each day because they may not always get this in their food.

What happens if toddlers don’t get enough iron?

If toddlers do not get enough iron, they can develop ‘iron-deficiency anaemia’ (or IDA). IDA is the commonest type of malnutrition in the world. It is estimated to affect 43 per cent of children worldwide. One in eight toddlers has IDA in the UK. Toddlers with IDA can be pale, lack energy and may feel tired all the time. Although rare, severe IDA can lead to breathlessness and even heart failure. As they grow, toddlers need enough iron so that their brain and movement skills develop normally. Severe IDA can affect long term performance at school.

Why does IDA happen?

Babies are born with enough iron stored in their liver to last for about six months, unless they are premature. Breast milk will provide a baby’s nutritional iron needs for 4-6 months, but after that the weaning diet and family foods must contain sufficient iron-rich foods to meet the high dietary iron needs of growing toddlers.

If toddlers are not given enough iron-rich foods then their dietary iron intake can drop below the recommended level. When this occurs, toddlers are at risk of developing IDA.

It is not uncommon for toddlers to be short of iron. Reasons for this can include the drinking of large volumes of cow’s milk, which does not have any iron in it, , or the toddler eating a family diet that is low in iron. Children who have behavioural and eating problems are also at greater risk of developing IDA, as are children who eat little or no meat.

How is IDA treated?

If you think a toddler has IDA advise the parents to take him or her to see a GP. A simple fingerprick blood test can diagnose IDA. It is treated with a daily iron supplement (3mg iron/kg) and by ensuring the toddler eats an iron-rich diet.

What foods contain iron?

Iron exists in two forms: the well absorbed ‘haem’ form, and the less well absorbed ‘non-haem’ form.

• The ‘haem’ form of iron is found in meat, such as beef, lamb, pork, liver, poultry meat and chicken breast and oily fish.
• The ‘non-haem’ iron is found in leafy green vegetables, iron-fortified breakfast cereals, pulses, nuts, eggs, dried fruit, bread and oats. Examples of pulses are lentils, dhal, chickpeas, hummus and other starchy beans and bhajis or other foods made from lentil or chickpea flours.
• Eating foods that contain ‘non-haem’ iron with a source of vitamin C, such as fruit or fruit juice (but not fizzy drinks or squash), helps the body to absorb the iron.

Parents should use a dry child-size toothbrush with soft bristles. Toothbrushes should be replaced every three months or sooner if the bristles splay. When brushing, use:

• a smear of paste containing 1000 ppm of fluoride up to the age of three
• a pea sized amount of 1350-1500 ppm or fluoride paste over the age of three

One of the easiest ways to brush a toddler’s teeth is from behind. Comfortable and safe positions for the child are on the parent’s knee, sitting on a changing mat, in a baby chair / high chair or sitting in a pram or buggy. Don’t discourage young children who want to brush their own teeth, but parents should always follow this up by brushing their teeth as well. Children should not be allowed to run around with a toothbrush in the mouth because of the risk of injury if they fall.

As more teeth come through, it is important to develop a system of cleaning them that ensures all surfaces are brushed thoroughly. Children should be supervised until at least seven years of age and always told to ‘spit don’t rinse’ and not to swallow the toothpaste. Rinsing with water after brushing removes the benefit of fluoride. All babies and children should be registered with a dentist from the moment their first teeth erupt.

Researchers from Bristol University, who are following the health of around 14,000 children for the Avon Longitudinal Study of Parents and Children (ALSPAC), found that poor diet may be associated with small reductions in IQ in later childhood.

These findings correspond with earlier ALSPAC data that shows an association between diet in the early years and school performance and behaviour in later childhood.

It’s true that our brains grow fastest during our first three years of life, and toddlers’ eating habits shape cognitive performance as they get older. A nutritious, balanced diet during these early years is vital for positive mental development.

Some good news is that the same study suggests a healthy diet may be associated with small increases in IQ; nutrient-rich foods seem to actually boost cognitive performance as children grow up.

The Bristol researchers said toddlers’ diets could change IQ levels later in childhood, if eating habits improve with age. However, it is never a bad time to take positive steps to improve the diets of toddlers.

For advice on how to feed toddlers a healthy, balanced diet, see the Infant & Toddler Forum’s Ten Steps for Healthy Toddlers and our Factsheets Combining Food for a Balanced Diet, How to choose nutritious fresh or convenience foods, and Understanding Food Labels.

What regulations are in place for foods marketed at children?

Foods decorated with cartoon characters are designed to appeal to young children. However they can be of poorer nutritional quality than standard foods. Extra sugar is often added to breakfast cereals, yogurts and desserts to satisfy young children’s preference for sweet foods.

Pre-prepared toddler foods that are found in the baby aisles of supermarkets must comply with strict regulations on their nutrient content. If a food is labelled as suitable for an infant or toddler under three years of age (e.g. 10+ months) it must comply with regulations on nutrient content including a minimum level of certain key nutrients and a maximum limit on salt, sodium, fat and sugar. They must also comply with a very low maximum limit on pesticides.

The normal colour of the stools of babies can be very variable – from pale yellow to dark green or brown.

The colour is due primarily to certain bile pigments which are naturally excreted in the stool.

The stool in nappies can sometimes be mixed with urine, which can affect its colour.

The first stools passed by newborn babies are black, sticky and tarry. During the first week after birth they gradually change to a paler colour.

The stools of breast fed infants are generally paler yellow and softer than those of formula fed infants.

The colour of the stools often changes when babies start eating solid foods.

The stools of toddlers are usually brown; they may contain bits of food.

What is a baby’s stool made up of and how do these things influence its colour and consistency?

The stools of babies are made of a mixture of undigested food, waste products of the body, bacteria, mucus, cells shed from the lining of the gastrointestinal tract, and water.

Their colour is due primarily to certain bile pigments which are naturally excreted in the stool.

The bulk and consistency of the stools is determined largely by the balance between the amount of water and ‘non-digestible’ material (fibre which holds water and makes the stools moist) within them.

The amounts of water and non-digestible material (fibre) in the stools (and hence their size, and consistency) is affected by the milk and/or food that the baby is taking.

There is a relatively wide variation in what is normal, in terms of colour, size, shape, consistency and frequency.

What are the normal size, shape, consistency and frequency of the stools of babies and toddlers?

The size, shape, consistency and frequency of the stools of babies can be very variable.

The stools of babies are generally small and can range from soft and mushy to firm and formed.

The stools of breast fed babies are generally larger and softer than those of formula fed babies.

Breast fed babies dirty their nappies more frequently (up to five or six times a day) than formula fed babies (around twice a day) during the first four months of life. However some healthy breast fed babies can go for several days without passing a stool.

The colour, texture and frequency of the stools often change in formula fed babies if the formula milk is changed.

When babies start eating solid foods their stools become more formed, darker and are passed less frequently (average twice a day). The stools may also become ‘smellier’.

Healthy toddlers generally open their bowels between three times a day and once every three days. They produce a soft stool of the size of a small sausage.

Bits of food are often to be seen in the stools of normal healthy toddlers.

Water is a good choice because it contains no sugar or acid and will not damage the teeth. Make it available throughout the day.

All drinks that are sweetened with sugar, or naturally sweet with fruit sugar (e.g. fruit juices) can cause dental decay. Most are also acidic, which can damage teeth by eroding the tooth enamel.

The following are best avoided but if given should be limited to only one serving per week:

• Squashes/cordials
• Fizzy sweet drinks
• No added sugar drinks that contain fruit juice
• • Fruit juices and smoothies including those diluted with water – these high calorie drinks are sugary and acidic. Although they provide some nutrients, they are not a necessary part of toddlers’ diets because children can obtain adequate vitamin C by eating fruit and/or vegetables. If offered to toddlers, fruit juices and smoothies should be well diluted – one part juice to about six to ten parts water.
• Herbal teas sweetened with sugar or honey

Diet drinks and zero calorie drinks that contain no sugar will be acidic and should only be offered at meal times.

Fruit smoothies are very high in sugar and calories and are best offered as the sweet second course as part of a meal.

MILK DRINKS contain valuable nutrients for toddlers but also need to be limited.

From 12 months toddlers can have whole milk. Lower fat milks such as semi-skimmed milks have less vitamin A so are unsuitable before 2 years.

Milk and formula milks do not damage teeth but need to be limited to three drinks a day or less if toddlers are also eating yogurt and cheese.

Flavoured milk and yogurts contain added sugar, glucose or other forms of sugar, and should be offered only at meal times and no more than one snack each day:

Substitutes for milk such as soya milks, cereal milks, almond milks and other nut milks do not contain all the nutrients found in milk from cows and goats. They are not suitable for toddlers unless they are enriched with calcium, iodine, vitamin A and riboflavin.

Rice milks may have small amounts of arsenic and are not suitable for children under five.

Whey-dominant infant formulae (stage 1) have a protein ratio of 60 per cent whey and 40 per cent casein, which is similar to the whey/casein ratio in breastmilk. This forms a soft curd in the stomach which is easily digested.

Casein-dominant infant formulae (stage 2) have a protein ratio of 20 per cent whey and 80 per cent casein, which is the same whey/casein ratio as cow’s milk. This forms a firmer curd in the stomach, and is a slower-digesting protein. Gastric emptying is slower with this milk compared to the whey-dominant milk.

Both stage 1 and stage 2 formulae can be used in children under the age of six months.

All infant formulae must comply with strict regulations set by the EU Directive.

IMPORTANT NOTICE: Breastfeeding is best for babies. Infant milk is intended to replace breast milk when mothers do not breastfeed. Infant milk should only be used on the advice of independent persons qualified in medicine, nutrition or pharmacy, or other professionals responsible for maternal and child care.

A drink should be offered at each meal, and once in between meals –with a snack if one is being given.

A drink portion counts as: 100-120mls (3-4 ozs) of any drink (including milk) or soup. A 200-240mls (6-8 ozs) bottle of milk is two portions.

Toddlers need less milk than they did in their first year of life, and bottles of milk are best discontinued by about 12 months. Toddlers who continue to drink bottles of milk are usually filling themselves up on milk and leaving less room for iron-rich foods and many go on to develop iron deficiency anaemia.

The UK Department of Health has recommended a dilution of 1 part juice to 10 parts water for many years as a common sense recommendation to reduce the acidic effect of juices on teeth. Northern Ireland also use the same recommendation for diluting fruit juices.

The Infant & Toddler Forum have used that dilution to be consistent with the Department of Health recommendation, although it is not evidence-based.

Toddlers do not need fruit juice, whether diluted or not, as they will obtain sufficient amounts of vitamin C from foods such as potatoes, fruit and vegetables. The latest NDNS surveys found that UK toddlers are having sufficient amounts of vitamin C in their diets and do not need extra (NDNS 2016).

We discourage fruit juices in toddlers’ diets as they are a high sugar, high calorie drink – even when diluted by 50 per cent.

Reference:

• 1. Department of Health (2012) National Diet and Nutrition Survey: Headline Results from Years 5&6 (combined) of the Rolling Programme 2012-2014. http://transparency.dh.gov.uk/2012/07/25/ndns-3-years-report/ (Accessed April 2018) Salt in the Diet.

If it’s good for growth, why should salt intake in toddlers be limited?

Children require only a small amount of salt in their diet for healthy growth and will naturally consume these amounts within a healthy diet. Children with a high salt diet may develop a preference for salty foods and we know that a high salt intake in later life can cause health problems such as high blood pressure.

By six months but not before four months

Parents can begin with a smooth mash or runny puree for the first few tastes. They should then move on to thicker purees or well-mashed food as their baby becomes used to taking food from a spoon. We suggest that they offer some soft finger foods as well.

Most parents start with rice-based cereal, mixed with their infant’s milk or mashed or pureed root vegetables or fruit. The following foods can then be added in but they should all be introduced singly so that any reactions can be noted: pureed lean meat, mashed or pureed fish, scrambled eggs, nut butters, plain yoghurt, grated cheese and other cereals such as oats and wheat. Other mashed/pureed vegetables, dhal, lentils and pulses can also be offered.

Soft finger foods include soft fruit pieces, cooked vegetable pieces or sticks, cooked pasta pieces, crusts of bread or toast, cheese cubes.

Six to nine months

At this stage parents can offer mashed food with soft lumps and soft finger foods. Meat may still need to be pureed but can be mashed if it is very soft. Nuts should be ground or as nut butter.

Widen the variety of foods offered to include all fruits, vegetables, meats, fish, eggs, pulses bread, rice, pasta and other cereals. Liver should be limited to one serving per week because of the very high vitamin A content.

Nine to 12 months

Move onto minced and chopped family foods. Finger foods such as raw fruit and vegetable sticks, as well as a variety of family foods such as sandwiches or toast and any of the food previously described above. Nuts should be crushed, chopped or ground.

When should I advise parents to start weaning?

Weaning onto smooth foods should start when the infant is between four to six months of age; but not later than six months, ideally whilst breastfeeding^1,2. Weaning can start when the infant shows signs of readiness: this will probably be because his or her appetite is no longer satisfied by milk (breast or formula) alone. He or she may also be watching or be interested in imitating others’ eating. Infants signal increased hunger, so that the parent knows when to introduce complementary food.

Parents report noticing sustained changes in behaviour between four and six months of age such as:

• sucking or chewing their fists
• crying between feeds³

which can indicate hunger if there is no other obvious reason for these behavioural changes.

Although for most babies, breast milk is nutritionally sufficient up to the age of 4-6 months, it would seem that there is a ‘window of opportunity’ or sensitive period for the introduction of the taste of foods prior to this age. Infants between four and six months need fewer exposures to a taste to acquire a preference⁴ – and exposure to a food taste is crucial in establishing a preference in all foods apart from those with a sweet taste^4,5. Infants are born with a preference for a sweet taste, but need to learn to like all other tastes^4,5. Relatively early exposure, therefore, is crucial in establishing a preference for the taste of foods with more complex or quite bitter tastes, such as fruit and vegetables.

Lumpy solid foods are best introduced around six months. The delay in introducing lumpy textures seems to lead to difficulty in coping with more solid textures than that of puree and bite and dissolve (see Factsheet 2.2), and a compromised acceptance of foods in later childhood^3,4,6,7.

References

1. 1. Iversson A, Hernell O, Stenlund H, Persson LA. Breast-feeding protects against celiac disease. Am J Clin Nutr 2002; 75(5):914-21.
2. 2. Agostoni C, Decsi T, Fewtrell M. et al. Medical Position Paper; Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gast Nutr 2008; 46:99-110.
3. 3. Harris, G. Determinants of the introduction of solid food. J Reprod Infant Psychol 1988; 6:241-249.
4. 4. Harris, G. Introducing the infant’s first solid food. Br Food J 1993; 95(9):7-11.
5. 5. Birch LL, Marlin DW. I don’t like it; I never tried it: effects of exposure on two-year-old children’s food preferences. Appetite 1987; 9(3):171-8.
6. 6. Northstone K, Emmett P, Nethersole F. The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. J Hum Nutr Diet 2001; 14(1):43-54.
7. 7. Coulthard H, Harris G, Emmett P. and the ALSPAC team. Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age. Maternal and Child Nutrition 2009; 5:75-85.

Probiotics (‘friendly’ bacteria) are living microbial food ingredients that are beneficial to health. They are specially selected bacteria which may protect against some diseases as well as aid the digestion of non-digestible substances, including prebiotics.

Probiotics are found in some yogurts and cultured dairy products.

Prebiotics are non-digestible ingredients (mainly carbohydrates) which provide nourishment to the bacteria that reside in the large bowel, and that stimulate the growth of ‘friendly’ bacteria. Prebiotics and the products of their digestion – short chain fatty acids – maintain the health and integrity of the lining of the bowel, and may strengthen the immune system.

Prebiotics occur naturally in breastmilk and are added to some infant formulas, breakfast cereals and some health foods. They are also found naturally in some foods, such as bananas, onions, asparagus, chicory, garlic and artichokes.

Acceptance in the first year of life:

Infants learn to like the foods that they are given and that they see others around them eating. They get used to the taste texture and smell of the food, and then identify the food by the way that it looks.

Rejection in the second year of life:

The food is rejected on sight.

There is a visual ‘mismatch’ between the foods that they have learned to like, and the new food. From an evolutionary point of view, rejecting food on sight is a sensible reaction; it would not be a good idea for a toddler to put a possibly poisonous substance in the mouth to test whether or not it was edible.
See Factsheet 2.3

What is the neophobic stage?

Neophobia means ‘fear of the new’. When this term is used with children in their response to food, it refers to the fear of new foods. The neophobic stage is seen from around the age of 15 months; it peaks at about two years, and then gradually becomes less strong through the toddler and pre-school years.

It has been suggested that this food refusal response is of evolutionary benefit. Infants who are just starting to be mobile will not put new ‘non-foods’, that might be poisonous, into their mouths.

At the onset of the neophobic stage toddlers might reject foods that are only slightly different from those that they usually eat, for example:

• a broken biscuit may be rejected, but a whole biscuit accepted
• toast that is burnt around the edges may be rejected, but uniformly coloured toast will be accepted.

This extreme rejection occurs because, at the early stages of neophobia, toddlers are focusing on the ‘local’ details of the food; that is, how the food differs from the prototype food that they have in their mind’s eye. As toddlers get older, and learn that foods can differ slightly in appearance, but still belong to the same category, then this extreme response disappears (in most children, but not all).

Rejection of previously accepted foods

In a way, the term ‘fear of new foods’ is a little misleading, because at this age toddlers tend to start to reject food that they have eaten before, as well as refusing to try new foods.

The disgust response

Food is also likely to be rejected at the neophobic stage because of its texture. Toddlers might find the texture of some foods slimy or lumpy, or too chewy. The texture of a food can be inferred by the way that it looks. So toddlers are more likely to reject foods of certain texture on sight.

If the children are:

• very sensitive to the feel of food in the mouth
• forced to eat foods that they have rejected

a strong disgust response to the food can also develop.

Most adults can remember their feelings of disgust at being made to eat a food that they did not like. These foods are usually those with an odd texture e.g. cauliflower cheese, tomatoes, liver.
See Factsheet 2.3

Is the neophobic response a normal developmental stage for all children?

Yes, most children, and adults, are to some extent neophobic. Most of us are reluctant to eat new foods and have to get used to them over a period of time. However, this trait is more extreme in some children and adults than in others, and the neophobic response seems to be stronger towards some foods than towards others.

• The neophobic response is a normal developmental stage, but with some variation.
• The response tends to gradually become less marked as the child gets older.

By the age of five years many children are able to accept new foods without protest.

The rejection of meat and fish seems to be genetically determined, whereas the acceptance of sweet foods and puddings is not. This is possibly because a preference for sweeter foods and easy textures is learned through exposure, whereas the reaction to food with a strong sensory component, such as a difficult texture or strong smell, is inherited.

Although most children will grow out of the extreme neophobic response, there is a small group of children, mainly boys, who do not. These children may carry on to later childhood with an extremely limited range of foods accepted, and a strong fear response towards new foods.
See Factsheet 2.3

It’s always good to ask families about the toddler’s eating habits – which foods and how much they usually eat at home.

Sometimes toddlers eat very small portions of food especially if they are tired, not feeling well, upset or distracted by a new environment, for example when first beginning at a new nursery or returning after holidays. Once they have settled in, some toddlers eat better at nursery than at home. Toddlers may also refuse foods altogether if they are unfamiliar with what is being served. At other times toddlers may eat larger portions if they really like the food offered or are particularly hungry, for example after a lot of active play.

In eating more at certain times and less at other times toddlers generally eat as much as they need. So parents and carers can be reassured that offering a balanced diet and then allowing toddlers to eat to their appetite is the best strategy. It also makes mealtimes enjoyable rather than turning them into battlegrounds with an expectation by the parent or carer that a toddler should eat a certain amount. Toddlers may take longer to settle in to a nursery if the meal times are stressful for them.

There are now several guides on how much to offer toddlers; they all differ a bit. The Infant & Toddler Forum has developed portions size ranges in household measures that your nursery can use as a guide when serving. The ranges have been calculated to check that the average amount provides enough energy and nutrients for toddlers’ growth, health and development.

Be prepared to give hungry toddlers a bit more of savoury foods or a bit less to toddlers with small appetites. With puddings and sweet foods, the maximum serving size should be limited to the upper end of the portion size range as some toddlers will happily overeat sweet foods and this can lead to obesity.

For the Infant & Toddler Forum’s portion size ranges, see our Factsheet Portion Sizes for Toddlers: (1-4 years). It recommends portion size ranges designed to ensure that the energy and nutrient requirements of toddlers (except for vitamin D) are all met; toddlers all need a supplement of vitamin D.