Every Baby Matters

Guidelines for good nutrition in Bradford and Airedale

Nutrition and 1-5 year olds
INTRODUCTION
Children up to the age of 5 years are undergoing a period of rapid growth in
the muscles, body tissues and the development of the brain. Their food and
nutritional needs differ markedly from those of babies, older children and
adults and as well as growth and development are affected by increasing
activity levels and a relatively small stomach capacity. This means that a large
range of vital nutrients have to be included within the smaller volumes of
food they consume. An appropriate diet and approach to food issues are
important factors in preventing many health and development problems in
young children and in their future including obesity, faltering growth and
stunting, iron deficiency, specific nutrient deficiencies, dental caries and
developmental delay. It is vital to help parents and carers make the most of
this important opportunity to influence their child's future health and
potential.
The guidelines below follow on from the previous guidelines in this series on
infant feeding and weaning and give current, evidence based and practical
information about:
Rising to the toddler challenge: Eating well for the family
Healthy Start Vitamins and Vouchers
Nutritional requirements for key nutrients for children aged 1-5 years
Energy Protein Fat Iron Calcium
Vitamin A Vitamin D Fibre Salt
Mealtimes and Tips for Establishing a Good Mealtime Routine
Drinks
Specific needs of vegetarian and vegan children
Common nutritional problems observed in the under 5's
Food Refusal and Faddy Eating Overweight and Obesity
Iron Deficiency Anaemia Vitamin D Deficiency
Constipation Food Allergy and Intolerance
Diet, behaviour and learning
Food Additives
Food safety considerations in the under 5's
Some Key Sources and Resources
Appendix 1: What is a portion: A guide for children aged 1 to 5 years
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Prepared by Bradford Nutrition and Dietetics Service January 2013
Telephone 01274 783124
 RISING TO THE TODDLER CHALLENGE: Eating well for the family
Establishing a regular meal pattern made up of 3 small balanced and
varied meals including 2-3 nutritious snacks is recommended as the
optimum way of ensuring a young child is able to meet their nutritional
requirements. Foods offered should be nutrient dense, meet (but not
exceed) energy requirements and be varied and appealing. This can be a
challenge for parents and carers, particularly during the toddler years when
young children are developing and learning to express their independence.
Parents and carers should be encouraged and supported to establish a regular
eating pattern providing and eating a variety of foods from the 5 food groups
so that young children become familiar with learning to making healthy food
choices from an early age. Children learn by watching the behaviour of those
around them so parents, carers and others are important role models. Healthy
family food for everyone will help young children develop good eating habits for
the future.
Detailed and practical advice about the 5 food groups and how to eat a healthy
diet can be found in the Live Well section of the NHS Choices website
www.nhs.uk/livewell and
www.nhs.uk/livewell/goodfood/pages/healthyeating.aspx
Providing food for a growing family (especially when time or money is short) can
require new skills and ideas for parents. As well as information on healthy eating
and support in learning how to manage children's behaviour around food,
support with developing practical skills such as cooking, planning meals and
snacks, shopping and budgeting for food, storing food safely may be helpful.

Healthy Start Vitamins and Vouchers

Even on a healthy balanced diet infants and children under 5 years may not get
enough of these vitamins, especially vitamin D. Advice should be provided on the
Healthy Start Scheme vitamin drops for children which are available free or at low
cost. Parents can get more information from their Health Visitor. Children up to
five are advised to have 5 drops every day of the Healthy Start Vitamins for
Children. For further information about the vitamins and the Healthy Start
Scheme, which also includes vouchers to help with the cost of fruit, vegetables
and milk for young children see www.healthystart.nhs.uk.

ENERGY AND ENERGY BALANCE

Children need energy for growth, development and activity. The energy needs of
each child are different and intake should be tailored to each child to ensure
optimal growth and development whilst avoiding overweight and obesity.
Energy requirements of young children are obviously less than those of adults but
they do double (approximately) between the ages of 1 and 5 years.
Getting energy balance right involves offering the right balance of foods in the
right quantities (or portion sizes) as well as appropriate physical activity.

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Average Energy Requirements (calories/kcals) of children aged 1 to 5

Age (years) Male (kcal) Female (kcal)

1 765 717
2 1004 932
3 1171 1076
4 1386 1291
5 1482 1362

* SACN Dietary Reference Values for Energy, 2011.

Energy is provided by carbohydrates (starchy food and sugars), protein and fat
in the diet. A healthy energy balance is most likely to be achieved by offering 3
balanced meals a day each containing some starchy carbohydrate food and 2-3
nutritious snacks. Portion sizes should be adjusted to the age and needs of the
child. Practical information about food portion sizes for 1-5 year olds is given in
Appendix 1.
The body stores energy to use on occasions when current dietary intake does not
meet immediate energy needs. If energy intake exceeds the amount used body
fat stores will continue to increase and this will lead to overweight and obesity. If
energy intake is below a child's energy requirements, all the body's energy stores
will be used up and then growth and development will falter and there will be
many other health problems such as increased susceptibility to infection.

Physical activity and energy balance

Daily physical activity is a vital part of achieving energy balance, preventing
obesity and promoting healthy development. It is recommended that young
children are physically active every day for at least 180 minutes (3 hours) and
more information is available from
www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-
children.aspx
Children under 5 should not be inactive for long periods, except when they're
asleep. Watching TV, or being strapped into a buggy or car seat for long periods
are not good for a child's health and development. There's growing evidence that
such behaviour can increase their risk of poor health.

CARBOHYDRATE – STARCHY FOODS AND SUGARS

Starchy carbohydrate food (eg bread, potatoes, rice, fortified breakfast cereals,
cassava, chapatti, pasta, crackers) should be given at each meal and at least one
snack during the day for children aged 1 to 5 years. They are a good source of
calories, provide B vitamins essential for growth and some fibre. A variety of
different starchy foods should be used in the diet.
Sugars (known as Non Milk Extrinsic Sugars - NMES) include table sugar, soft
drinks, fruit juices, confectionary, chocolate, cakes and biscuits. These foods
should be restricted in amount and frequency. They are a major cause of dental
caries and a concentrated source of energy often providing few other nutrients
('empty calories'). Excessive consumption is linked with overweight and obesity in
children and adults. Diets containing a high amount of NMES based foods are
often high in energy but low in other essential nutrients. Sugars (excluding those
naturally found in whole fruit and milk) should provide less than 10% of total 3
energy in the diet. For young children this will be approximately 33g per day (DH,
2009).
 Examples of amounts of NMES sugar in some typical portions of
food

Food Sugar content (g)

(rounded to nearest gram)

Sugar -1 teaspoon 4
Can of coke (330ml) 35
Flavoured milk drink (200ml) 19
2 finger Kit-Kat 10
Ribena carton (200ml) 21
Sugar puffs (30g portion) 11
Strawberry jam (1tbsp) 9
Milk chocolate buttons (35g) 21
Dolly Mixtures (25g portion) 20
Lucozade drink (380ml 52

PROTEIN
Adequate protein intake is essential for growth, development and repair of body
tissues in children. Foods naturally rich in protein include meat, fish, chicken,
eggs, beans, pulses and nuts. At least 2 servings of a variety of protein rich foods
should be provided per day. Vegetarian or vegan children will need up to 4
servings per day.
Average portion sizes of protein for 1-5 year olds;
½ - 3 tablespoons of chopped meat/chicken/fish
½ - 1 egg
½ - 2 fish fingers
½ - 3 tablespoons of beans/pulses/lentils
These foods are often the major contributor of iron in a child's diet and children
under the age of 5 years have a high requirement for iron in relation to their
body size. When these foods are offered, a food or drink rich in vitamin C should
also be included at the same meal. Vitamin C enhances the absorption of iron in
the gut. Food and drinks rich in vitamin C include potatoes, tomatoes, citrus
fruits, dilute pure orange juice (50% juice:50% water), kiwi fruit, most summer
berries, peppers, and vitamin C fortified drinks e.g. Ribena and C Vit .

FAT
Fat is an essential contributor to overall energy intake in the under 5's as it can
provide a lot of calories in a small amount, without making the diet of a small
child bulky.
The healthiest options are olive, rapeseed and groundnut oils or fat spreads made
from these. They are also a good source of vitamin A, D and E and can provide a
good balance of omega 3 and 6 essential fatty acids. Fats high in saturated fats
such as butter, lard, dripping and some hard vegetable fats should be limited in
use and used only occasionally.

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Foods high in fat which otherwise contain very little nutrients other than
calories, such as pastries, cakes, biscuits, crisps, fast, fried or processed
foods should be limited in a child's diet. Low fat, low calorie or 'diet'
alternatives are not usually suitable for a rapidly growing child as they
may not provide enough energy. Full fat milk (which is only about 4% fat)
is recommended as the main milk for children up to 5 years as the fat
provides vital energy and fat soluble vitamins. However if a younger child
is consistently eating a balanced diet and growing well (or is found to be
overweight or obese) semi -skimmed milk can be given as the main milk from
2 years and skimmed milk from 5 years.

Tips for healthier cooking:

Instead of frying or roasting using a lot of fat try
steaming
poaching
dry roasting
stir frying – using a small amount of oil only
braising
microwaving
baking
grilling
Limit fried foods and pastry
Avoid adding a lot of extra fat, oil, butter, ghee or cream to foods
Trim excess fat from meat and remove skin and fat from chicken before cooking

IRON
Iron is an essential component of haemoglobin, found in red blood cells and
requirements are high in the under 5's. This is reflective of the rapid growth and
development seen in this age group.
Reference Nutrient Intakes (RNI) for iron are;
Age (years) RNI(mg)
1-3 6.9
4-6 6.1
DH, 1991.

Iron is found in red meat, oily fish, eggs, nuts, beans and pulses, fortified
breakfast cereals, dried fruit and dark green leafy vegetables.

Food rich in iron Iron content (mg)

3 tablespoons breakfast cereal 1.2
2 tablespoons Dhal 1.5
2 tablespoons broccoli 0.6
1-2 tablespoon lamb 1.0
1 medium egg 1.1
2 tablespoons oily fish 1.6 5
2 tablespoons of spinach 1.0
 Iron is absorbed more efficiently in the presence of vitamin C rich foods
and drinks. Vitamin C rich foods such as citrus fruits, diluted pure
orange juice, kiwi fruit, berries, potatoes, peppers, tomatoes, mangoes,
beansprouts and vitamin C fortified drinks should be offered at the same
time as iron rich foods at mealtimes.

CALCIUM
Calcium is needed for building strong and healthy teeth, bones, an efficient
nervous system and for muscle action.
The Reference Nutrient Intakes for calcium are;

Age (years) RNI(mg)

1-3 350
4-6 450

Dietary sources of calcium for children under 5 years include milk, cheese,
yoghurt, fromage frais, custard, milk based puddings (semolina, rice pudding and
tapioca), breakfast cereals fortified with added calcium, tinned fish where the
bones are eaten (sardines, pilchards, salmon), calcium enriched soya milk and
desserts and foods made with white or cheese sauces. Vegetarian and vegan
sources include tofu, nuts and nut butters, seeds, figs, beans, lentils and pulses,
okra, oranges and spinach.
Offering 3 small servings per day as part of a balanced diet will help to meet the
nutritional needs of most children under 5 years. A serving is about 120ml of
milk (either as a drink or in food), 120g pot of yoghurt and a small matchbox
serving of cheese. It should be noted that as a child grows, serving size will
increase according to appetite providing more protein and calcium relative to
requirements.

Calcium content of commonly eaten foods

Food rich in calcium Calcium content (mg)

180mls milk 240

40g cheddar cheese 200
150g yoghurt 225
120g custard 120
2 slices white bread 65
Average serving of pizza 350
3 tablespoons of spinach curry 140
50g tofu 250
1 medium sized orange 75
2 figs 85

Lower fat dairy products (eg milk, yogurt) have the same amount (or more)
calcium in them as full fat versions.
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VITAMIN A
Vitamin A plays a vital role in maintaining a healthy immune system,
fighting infection and for good vision in dim light.
The Reference Nutrient Intake (RNI)for Vitamin A is;

Age (years) RNI (ug)

1-3 400
4-6 400

DH, 1991.
Good food sources of vitamin A include cheese, eggs, oily fish, fortified
breakfast cereals and margarines and yellow or orange based fruits and
vegetables (carrots, peppers, papaya, tomatoes and apricots).
Healthy Start Children's Vitamin drops contain 233 ug vitamin A (as well as
vitamin D and C) and should be given to all children from soon after birth and up
to 5 years.

VITAMIN D
Vitamin D is a hormone needed to keep teeth and bones healthy and deficiency
of vitamin D can lead to Rickets in children. Young children are especially
vulnerable to vitamin D deficiency because of their rapid growth and limited
exposure to sunlight. Young children need between 7-8.5 ug (280-340IU) of
vitamin D each day.
Children aged from 1 to 5 years who are at risk of vitamin D deficiency need at
least 7.5 ug (300IU) a day.
In babies and young children, signs and symptoms of vitamin D deficiency are;
lethargy and irritability
poor growth
delayed teething
soft skull bones, swollen joints or bowed legs
muscle spasms and seizures
Vitamin D is mainly derived from the action of the sunlight on the skin (about
90%) and a small amount obtained via the diet (about 10%). Because it is so
difficult to get sufficient Vitamin D from the diet and sunlight a supplement is
recommended. Healthy Start Vitamin Drops contain 7.5ug (300iu) Vitamin D as
well as vitamins A and C and should be given from soon after birth until five
years. Sufficient and safe skin exposure to sunlight and the inclusion of foods
rich in Vitamin D in the diet daily are also important in preventing deficiency
(There is more detailed information later in the Section on Common Nutritional
Problems in Young Children)

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 Good Food Sources of Vitamin D
Oily fish – sardines, pilchards, salmon, fresh tuna, mackerel,
herring, trout, whitebait, herrings, ilisha, pangas, tengra and
ba-eem
Breakfast cereals fortified with vitamin D – check the label
Margarines (fortified with Vitamin D)
Egg yolks
Liver
Evaporated and some powdered milks
Some yoghurts – check the label
Mushrooms

FIBRE
Dietary fibre helps to keep the digestive system healthy and prevent constipation
as well as other health problems. It is found in fruit and vegetables, beans and
pulses, breads and cereals –especially wholegrain varieties. Including appropriate
amounts of fruit and vegetables every day (see Appendix 1) as well as breads and
cereals will help to provide fibre. Very high fibre diets (ie one consisting of mainly
vegetables, beans, pulses and wholegrain cereals) can be too bulky for young
rapidly growing children (with small appetites and stomachs) who, unlike adults,
may not be able to eat enough of this type of diet to obtain enough energy for
optimal growth.
Bran should not be given to the under 5's as it can cause bloating, wind, loss of
appetite and can reduce the absorption of essential minerals such as calcium,
iron and zinc.

SALT
The main source of salt (also known as sodium chloride or referred to as sodium
on nutrition labels) is from table salt, processed foods and takeaways. High salt
intakes are linked with high blood pressure and kidney problems. It may also lead
to excessive fluid intake which can aggravate bedwetting. Encouraging
parents/carers to limit their child's intake of salty foods may help children to not
acquire a lasting taste for salty foods.
The Department of Health (DH) recommends salt (or sodium) should be limited in
children under 5 years:

Age (years) Salt (g) Sodium(g)

1-3 2 0.8
4-6 3 1.2

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Strategies which can be used to limit intake of salt in a child's diet
include:
salt not to be added to food at the table
limit the amount of salt, gravies, stock cubes, boullion, flavoured salts,
readymade sauces and other salty condiments used in cooking
limit the amount and frequency of processed foods offered to children
such as tinned soups, cured meats, processed foods, ready made meals
and snacks, frozen meals, crisps and other salty snacks.
Using herbs, spices or other foods to flavour food such as fresh/dried herbs,
chilli, lemon juice, garlic or fennel.
Salty snack foods like crisps, processed /convenience foods manufactured
specifically for children and some breakfast cereals can also be high in fat,
saturated fat and calories and should only be offered occasionally.

MEALTIMES
Toddlers and young children have small stomachs but high nutrient needs. It is
important to establish a regular meal pattern made up of 3 balanced meals and
2-3 nutritious snacks to ensure optimal growth and development is achieved.
Establishing a routine can be reassuring for a child and also helps to develop,
social, motor and behavioural skills associated with eating.

More information on portion sizes, balanced meals and snacks and for practical
guidance on understanding a young child's nutritional needs can be obtained
from the Infant and Toddler Forum:
https://www.infantandtoddlerforum.org/little-peoples-plates
Guideline amounts on what is a portion for children aged from 1 to 5 years can
be viewed in Appendix 1

Tips for establishing a good mealtime routine

at least one parent/carer should eat with young children to encourage positive
role modelling
ensure mealtimes are happy and pleasant experiences
children should be sitting comfortably and using utensils appropriate to age
and motor skills
2 courses should be offered at each main meal – a balanced savoury course
followed by a nutritious pudding
offer small portions to begin with - more can be offered if needed
allow children to decide when they have eaten enough and do not push them
to clear their plate
encourage self feeding as much as possible
never leave young children unsupervised at mealtimes
accept mess as part of the normal feeding and development process.
Sweets and puddings should not be used a bribe or treat
Praise toddlers when they eat well
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 DRINKS
Children should be offered 6-8 beakers or glasses of fluid per day, where
a portion of fluid for young children would measure between 100-
150mls. They will need more in hot weather, fever or after extra physical
activity as young children can dehydrate very quickly. Water and milk are
the recommended main drinks for children.
Pure fruit juices contain large amounts of fructose (a naturally occurring
fruit sugar) and are acidic. If offered, pure fruit juice should be diluted well
(50% water and 50% juice) and only be given at mealtimes.
Fizzy drinks and squashes contain large amounts of added sugar and
contribute to tooth decay and overweight and obesity. These drinks are
considered unnecessary in a child's diet as they provide “empty calories” and
very little, or if at all any other nutrients. Caffeine containing fizzy drinks (eg
cola, energy drinks) can cause sleep problems and bedwetting.
No added sugar/low calorie drinks can contain natural sugars and acids and
can still contribute to tooth decay. These include baby juices, natural fruit juices
and sugar free squashes and should be limited in a young child's diet.
Tea, coffee, fruit teas and high energy drinks are not recommended for young
children because they contain compounds called tannin and polyphenols. These
bind with iron in the diet and reduce the availability of iron to the body. They
also contain caffeine, a mild stimulant which can aggravate bedwetting and sleep
problems. These drinks are unsuitable in a child's diet.
Soya drinks are often labelled as soya milks. Particular care should be paid to
ensure these drinks are nutritionally adequate and that they are fortified with
vitamins and minerals, especially calcium. Soya drinks can be high in sugar
content and attention should be paid to safeguard dental health. If children are
given soya drinks they should be given in a cup because of the sugar content.
Rice/Oats/Coconut milk are not recommended for children under 5 years as they
are nutritionally poor in value, can be high in sugar and can contain high levels of
arsenic.
Flavoured milk drinks
Many of these drinks can contain a significant amount of NMES which can
contribute to tooth decay.

VEGETARIAN AND VEGAN DIET

Children are different from adults because they are growing and therefore have
high nutritional requirements, especially during periods of rapid growth. The
main nutrient at risk for 1-5 year olds that do not eat meat or meat products is
iron. Iron from vegetarian and vegan foods is less well absorbed than from meat
and oily fish. Omega 3 oils (important for normal brain and eye development)
may also be low in diets that also exclude oily fish.

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 Points to consider when providing meals to vegetarian and vegan
children;
Offer 3-4 servings of protein foods daily
Include a food or drink rich in vitamin C at each mealtime
Ensure a variety of different starchy foods are offered at each
mealtime
Offer fortified breakfast cereals (those with added iron and vitamin D)
Regularly include plant based sources of omega 3 rich foods
(rapeseed, olive or grapeseed oil and fat spreads and walnuts if oily
fish is excluded from the diet)
Vegan diets are not advised for growing children as they are bulky, can
be low in energy and may not provide adequate amounts of vitamins
and minerals needed for achieving optimal growth.
A child whose parents insist on a vegan diet should be referred to a
Registered Dietitian for assessment as they may not be meeting their
needs for energy, protein, iron, vitamin D, zinc and vitamin B12. A
calcium enriched and vitamin fortified soya milk can be used from 1 year
as a cow's milk substitute.

COMMON NUTRITIONAL PROBLEMS IN YOUNG CHILDREN

Food Refusal, Faddy Eating, or Fussy Eating
Food refusal and faddy eating are part of normal development of a young child.
Sometime during their second year toddlers usually become more fussy about
what they will eat but most faddy eating improves with time.
Toddlers may:
Eat less than expected
Refuse to taste new foods
Refuse to eat foods they have previously eaten well
Some toddlers are more wary of new foods and refusal of foods is more
common in toddlers who were not offered a variety of tastes and textures during
weaning. Fussy Eaters will take much longer to learn to like and eat new foods
during infancy but over time, with patience and consistent exposure almost all
toddlers will outgrow this phase.
From around 3 years some children may start to refuse foods for other reasons
such as
Associating food with an object that is disgusting to them eg noodles may
resemble worms
Foods look slightly different to the food they are familiar with eg if a piece of
apple has a mark on the skin, a yogurt is a different colour or in a different
container
A biscuit is broken not whole
A liked food may be touching or even on the same plate as a disliked food

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 This is part of normal development behaviour in young children.
Occasionally, poor eating can be due to other factors;
Poor oral-motor development which may or may not be associated
with other development delay or cerebral palsy. A team approach
involving a dietitian and speech and language therapist would be ideal
in helping to resolve this issue.
Constipation, anaemia or other medical conditions need to be treated
before trying to change eating behaviour
Extreme sensory sensitivity. When there is nothing medically wrong with
the child who is an extremely faddy eater, it may be because the child has an
extreme anxiety about trying new foods or has an extreme reaction to the
different senses, touch, taste and smell. These children also usually dislike
getting their hands and face dirty.
Quite often children grow out of this and start to improve at around five years.
It is especially important that these children are not forced to eat foods that
they dislike as it may lead to vomiting.
A very small number of children do not grow out of this phase and continue to
restrict the foods they eat throughout childhood. Referral to a Registered
Dietitian may be necessary to assess food intake is sufficient to aid normal
growth and development.
Parents and Carers should have realistic expectations of the child's food intake
based upon appetite, portion size, rate of growth, body size and activity.

Managing Food Refusal and Faddy Eating behaviour

When concern is raised about a child's eating pattern, food choices, or eating
behaviour their growth and dietary intake should be assessed. Growth should be
assessed by a suitably qualified practitioner by measuring weight and height
accurately and plotting on growth charts. Parents can be asked to record a 3-7
day food diary to enable assessment of food and drink frequency and food group
content. If the child is growing normally then reassure the parents that the child
is eating adequately and any advice provided on food choices and achieving a
balanced diet should be based upon the principles of the Eatwell Plate.
Appropriate guidance and support can give parents/carers the confidence to
manage poor eating and food refusal.

Helpful strategies for parents/carers

A consistent approach for all those involved is essential
Not to pressure, bribe, or force feed a child
Sweets or puddings should not be used as a bribe or treat
Offer a regular meal pattern of 3 meals and 2-3 planned snacks each day
Give praise even if a small quantity of food is eaten
Take away any uneaten food without comment at the end of the meal
Limit mealtimes to 30 minutes and snack times to 20 minutes.
Keep calm and be patient

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There are a small but significant number of children whose faddy eating
may result in underweight or faltered growth. Where parents or carers
concerned about this should be encouraged to consult their Health
visitor/GP in the first instance. There is practical information on the NHS
choices website on managing underweight in children aged 2-5 years
www.nhs.uk/Livewell/Goodfood/Pages/Underweightyoungchild.aspx .
Faltering growth may need involvement of a paediatrician /dietitian.
Specialist multi-disciplinary teams can help with specific strategies
addressing factors affecting food related behaviour.

Overweight and Obesity

Obesity in 1-5 year olds is increasingly prevalent with 1 out of 5 young child
being either overweight or obese. Most children become obese because of their
lifestyle. Eating patterns, activity levels, ethnicity, genetics and environment all
play a part. If the food energy (calories ) eaten is in excess of the energy used for
physical activity and growth then the excess energy is stored as body fat.
Overweight and Obesity should be measured on a Body Mass Index (BMI) chart
for children.
Management of overweight and obesity should be based upon a whole family
approach using the Eatwell Plate healthy eating principles and establishing
adequate activity levels.
The current United Kingdom physical activity recommendations for Early
Years are;
Children of preschool age who are capable of walking should be
physically active daily for at least 180mins (3 hours), spread throughout
the day
All under 5's should minimise the amount of time spent being sedentary
for extended periods (except time spent sleeping)

Obese under-fives do not need to lose weight but the family lifestyle will need to
change so that weight gain slows down or stops for some time so that the BMI
decreases as the child grows taller.
Parents should be encouraged and supported to
Limit the amount of fatty and sugary foods and sugary drinks the child has.
Avoid giving 'diet' foods. Semi skimmed milk can be given after 2 years.
Children should be allowed to stop eating when they have indicated they have
had enough, they should not be pressured to finish all the food on their plate.
For more information see
www.nhs.uk/Livewell/childhealth1-5/Pages/Overweight2to5.aspx

Iron Deficiency Anaemia

Iron Deficiency Anaemia is the most commonly reported nutritional problem
during early childhood. When children are anaemic the blood is unable to supply
all the oxygen the body needs. The incidence tends to be higher in inner city or
deprived areas, South Asian (especially Pakistani) populations and toddlers with
feeding problems. Iron Deficiency Anaemia is often associated with faddy or
fussy eating behaviour.
Signs and symptoms of iron deficiency include pallor, tiredness, (lethargy) poor
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appetite, poor weight gain, frequent infections and developmental delay.
 Tips to Prevent Iron Deficiency Anaemia
Advise parents on introducing a wide range of foods, including iron
rich foods and iron fortified breakfast cereals.
Discourage use of a bottle after the age of one year as this often
encourages children to fill up on cow's milk instead of eating sufficient
solid food.
Drinks of tea should not be given at all and especially at mealtimes
because this reduces the absorption of iron from foods.
Vitamin C in fruit juice helps the body to absorb iron from food but should
be well diluted.
Offer Vitamin C rich foods at mealtimes to assist iron absorption.
If children do not eat meat encourage to include oily fish, fortified cereals,
lentils, dhal, other beans and pulses along with dark green leafy vegetables. It is
particularly important to include Vitamin C rich foods at each meal.

Vitamin D Deficiency
In Bradford, children are especially at risk of developing vitamin D deficiency due
to a large ethnic population, deprivation, food poverty and lifestyle factors which
limit exposure to sunlight.
Children who may be at increased risk of developing vitamin D deficiency include
those who;
are from Black and Minority Ethnic groups who have darker skins
are faddy eaters or those with poor eating habits
have poor or restrictive diets (vegans or vegetarians)
cover their skin or those who are strict sunscreen users
are weaned late
are exclusively breastfed babies
continue on breastmilk after 1 year
are formula fed on less than 500mls of infant formula a day
have metabolic, kidney or liver disease
spend a lot of time indoors
are born preterm (<37 weeks gestation)
are close in age with their siblings
are going through a period of rapid growth
Less commonly, children with chronic conditions or those who are taking
medication which interferes with vitamin D metabolism, may also be at increased
risk of developing vitamin D deficiency.
In Bradford, all infants from birth to six months receive free Healthy Start
Children's vitamin drops. After six months, those infants assessed to remain at
risk of vitamin D deficiency will continue to receive free vitamins till they are 2
years old. Families who are eligible for the Healthy Start Scheme will receive free
vitamins for their child from 6 months to four years and uptake of the Healthy
Start Scheme should be actively encouraged. Children who do not qualify for the
Healthy Start Scheme and who are considered at low risk of Vitamin D deficiency
14 will be able to purchase Healthy Start Children's vitamin drops for a small cost
from community health centres.
The amount of sunlight needed to make sufficient amounts of vitamin D
can vary. In the UK, children should be encouraged to play in the sun
without sunscreen for a total of 15-20 minutes between the times of
11am-3pm most days during the summer months (April to September).
Children's skin can burn easily so care should be taken to prevent
reddening and burning. Children with darker skin may need more time in
the sun to make enough vitamin D compared to children with fair skin.
NHS Bradford and Airedale, in partnership with Bradford Teaching Hospitals
NHS Foundation Trust and Airedale NHS Foundation Trust have developed a
care pathway on how to detect and manage vitamin D deficiency in young
children.

Poor Oral Health

The principal cause of tooth decay is the frequent intake of foods or drinks
containing sugars and Non Milk Extrinsic sugars (NMES) are the prime
contributors. There is a concern that there are high levels of consumption of
NMES amongst pre-school children.
Tooth decay is most often caused by frequent intake of foods or drinks
containing sugars and sticky foods that leave a residue around the teeth.
Erosion of tooth enamel is another dental problem in children caused by
frequent consumption of acidic drinks such as fizzy drinks and squashes. Pure
fruit juices can also erode teeth and should be diluted well and limited to
mealtimes..

Building Brighter Smiles

The PCT has implemented evidence-based preventive programmes and
commissioned appropriate NHS primary dental services to meet local oral health
needs of children under five.
Programmes have been commissioned that specifically address the poor oral
health of young children and come under the 'Building Brighter Smiles' name.
Three programmes that are particularly aimed at this age group are the Health
Visitor led Brushing for Life fluoride toothpaste distribution programme. The
'First Steps to Healthy Teeth' dental award is based in early years settings and has
an emphasis on healthier eating – a diet that is good for oral health will also
benefit general health. It was developed with Bradford District Care Trust Salaried
Dental Service, Bradford EYCP and Bradford Nutrition and Dietetic Service.

15
 Key messages to promote good oral health are:
The frequency and amount of sugary food and drinks consumed
should be reduced to no more than 4 intakes of sugar per day
including mealtimes.
Avoid giving sweets and biscuits as treats
All drinks should be taken from a cup, not a bottle. Only plain milk
or water between meals.
No sugar should be consumed within one hour of bedtime.
Teeth should be brushed twice daily with fluoride toothpaste as
soon as the first teeth erupt at night and one other time.
Use a smear of fluoride toothpaste of at least 1000 ppmF for
children aged 0 – 3 years and a pea-sized amount of 1350 –
1500ppmF toothpaste for all children aged 3 – 6 years.
Young children should be supervised until at least 7 years old as they
are unable to brush properly themselves.
Spit out excess toothpaste but do not rinse.
Avoid brushing teeth for one hour after consuming acidic drinks.
Regular checkups by a dentist as advised.
Sugar free medicines should be recommended

Constipation
Constipation is a common problem seen in young children and the causative
reasons can be complex. Symptoms include infrequent opening of bowels, hard
and painful to pass stools or refusal to go to the toilet to empty bowels.
The management of constipation can require laxatives, a higher fibre diet and
behaviour modification. Dietary advice to prevent or to treat constipation in
young children should include;
adequate fibre intake – Include higher fibre foods in the diet and aim for at
least 5 portions of fruit and vegetables daily
adequate fluid intake – some children are poor drinkers and should eb
encouraged to have 6-8 cups of fluid daily. Some children may need more due
to increased activity, fever or during warmer weather
adequate physical activity – sedentary behaviour should be discouraged and
children encouraged to be active for at least 180 minutes(3 hours) daily.

Food Allergy and Intolerance

Food allergy and intolerance are types of food sensitivity. If a child has a food
allergy their immune system mistakes a food as unsafe and this causes a serious
and possibly life-threatening reaction. A food intolerance also causes a reaction
but it does not involve the immune system and generally is not life-threatening. It
may make them feel ill or affect their long-term health.
Some parents suspect that their children are sensitive to foods but only 2-5%
actually has allergy or intolerance and most have grown out of this by the time
they are 1 year old. If parents do suspect their child has a food sensitivity they
should seek advice from their GP or Health Visitor. Health Professionals should
16 refer to NICE Clinical Guideline Food Allergy in Children and Young People
(CG116) for information on the diagnosis and assessment of allergy in primary
and community care settings.
Children who continue to be breastfed after 12 months of age and their
breastfeeding mothers should of course avoid any foods they are allergic
to themselves or where an allergy to that food has been diagnosed in the
breastfed child. If whole food groups (eg dairy) or many foods are
excluded from the diet, care needs to be taken to ensure that key
nutrients are replaced. Dietetic advice should be sought. Specialist infant
formula milks are available on prescription for children with allergies or
intolerance. Dietitians can advise further about specialist formula milks

DIET, BEHAVIOUR AND LEARNING

Evidence suggests that enjoying regular meals, enough fluids and a healthy
balanced diet as described above helps a child to have the best chance at
optimal mental and behavioural performance. Sufficient sleep and physical
activity are also important. Hunger, thirst and tiredness in small children will
often lead to behaviour problems. A poor or erratic diet will affect a child's
development, concentration and behaviour–particular issues to be aware of
include iron deficiency anaemia, faltering growth, dental caries and associated
pain, dehydration and high intakes of sugary food and drinks or caffeine.
For more detailed information see the British Dietetic Association Fact Sheet on
Children-Diet, Behaviour and Learning at
www.bda.uk.com/foodfacts/index.html

Food Additives
Research suggests that eating or drinking some artificial food colours and the
preservative sodium benzoate could be linked to increased hyperactivity in some
children. It is important to remember that hyperactivity is also linked to other
factors so avoiding certain additives may not be the total solution.
If children show signs of hyperactivity or if parents have concerns then avoid
giving food or drinks containing the following artificial colours:
tartrazine (E102)
ponceau 4R ( E124)
sunset yellow (E110)
carmoisine ( E122)
quinoline yellow ( E104)
allura red ( E129)
These colours are more commonly used in processed or convenience foods, often
which provide “empty calories” and are poor in overall nutrient quality such as in
confectionary, cakes, ice cream and soft drinks which are brightly coloured.

17
 FOOD HYGIENE AND SAFETY
Children under 5 years are vulnerable to food poisoning and can become
very ill very quickly so it is important to store, prepare and cook food
safely for them.
Tips to remember when preparing foods for young children:
Wash all fruits and vegetables before eating.
Take care to follow storage and cooking instructions on food labels.
Keep packed lunches chilled or in a cool bag
When re-heating food, make sure that it is piping hot throughout and check
the temperature of the food before feeding the child to avoid burning.
Don't give food after its 'use by date'
If providing eggs or shellfish, ensure they are well cooked.
Avoid shark, swordfish and marlin due to their high mercury content.
Teach children to wash their hands before eating and after going to the toilet.

Further information on how to maintain good standards of food safety and

hygiene for young children can be viewed at the NHS Choices /Livewell website:
http://www.nhs.uk/conditions/pregnancy-and-baby/pages/food-safety-
hygiene.aspx

Some Key Sources and Resources

Bradford Nutrition and Dietetics Services
Menu Planning Toolkit for Early Years in Bradford District (2nd edition 2012)
Model Food and Nutrition Food policy and checklist for Early Years (due 2013)
(Contact the Public health dietetic team 01274 78 3124 for more information)

Caroline Walker Trust 2006, Eating Well for Under 5's in Childcare 2006 Second
Edition CWT www.cwt.org.uk/pdfs/Under5s.pdf

Children's Food Trust (2012 ) Voluntary Food and Drink guidelines for Early Years
Settings in England
www.schoolfoodtrust.org.uk/resources/eat-better-start-better-
resources/guidelines

Department of Health, 1991 Dietary Reference Values for Food Energy and
Nutrients for the United Kingdom, London

Department of Health 2009 Delivering Better Oral Health: An evidence-based

toolkit for prevention 2nd Edition

Department of Health (July 2011) UK Physical Activity Guidelines for Early Years
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_127931

Healthy Start website (including sections and resources for parents and health
18 workers) www.healthystart.nhs.uk
Infant and Toddler Forum:
www.infantandtoddlerforum.org/little-peoples-plates

Lawson, M.S. Thomas, M. Hardiman, A. (1998) Iron status of Asian

children aged 2 years living in England. Archives Diseases in Childhood, 78
(5), p. 420-426.

McCance and Widdowson's The Composition of Foods, Sixth Edition, 2002.

Food Standards Agency.

Ministry of Agriculture, Fisheries and Food 1990, Food Portion Sizes, Second
Edition, London HMSO

NHS Choices Live Well Website

www.nhs.uk/LiveWell/Pages/Livewellhub.aspx
This contains a wealth of reliable and practical information about food and
health and feeding children. The sections on Food and Health and Healthy Eating
contain general information and the Babies and Toddlers pages contain
additional information for under fives. Links are given to some useful pages in
the text above but there is much more on the website.

NHS Health Scotland (July 2012) Oral Health and Nutrition Guidance for
Professionals

Pathway for pre-pubertal children at risk of or with Vitamin D deficiency/

depletion in primary care 2012
NHS Bradford and Airedale, in Partnership with Bradford Teaching Hospitals NHS
Foundation Trust and Airedale NHS Foundation Trust

Scientific Advisory Committee on Nutrition (SACN) 2007

Update on Vitamin D Position Statement
www.sacn.gov.uk/pdfs/sacn_position_vitamin_d_2007_05_07.pdf

Scientific Advisory Committee on Nutrition (SACN), Dietary Reference Values for

Energy, 2011, London TSO
www.sacn.gov.uk/reports_position_statements/reports/sacn_dietary_reference_
values_for_energy.html

Thomas, B. Bishop, J. eds. (2007) Manual of Dietetic Practice. Fourth edition.

Blackwell Publishing and the British Dietetic Association

Author: Bradford Dietitians, Bradford Teaching Hospitals NHS Foundation Trust

Date: January 2013
Review due: March 2015

19
 Appendix 1; WHAT IS A PORTION?
A GUIDE FOR YOUNG CHILDREN AGED 1 – 5 YEARS OLD

Number of portions a day 1 year 2-3 years 3-5 years

Bread, rice, potato, pasta, ½ -1 medium slice bread 1 medium slice bread 3-5 years1-2 medium slices
chapatti 1 tbsp mashed potato or 1 -2 tablespoon mashed bread
(4-6) rice(30g) potato (30-60g); 6 smallish 2-3 tablespoon mashed
1 tbsp porridge chips potato (60-80g); 8-10 chips

or ½ weetabix 1-1½ tbsp cereal 2-3 tbsp cereal

¼ small chapatti or 1 weetabix or 1-1½ weetabix

½ small chapatti 1 small chapatti

Meat, fish, egg and ½-1tbsp finely chopped 1 ½ tbsp chopped meat or 2-3 tbsp chopped meat or
alternatives meat or fish fish fish
(2-4) 1/2 – 1 hard cooked egg 1 egg 2-3 tbsp baked beans
½ -1 tbsp baked beans 1 ½ tbsp baked beans 1-2 fish fingers
½ fish finger 1 fish finger 1-2 sausages
½-1 tbsp lentils 1 sausage 2-3 tbsp lentils

Fruits and Vegetables ½- 1 small piece fruit e.g. 1 small piece e.g. apple, 1 small piece e.g. apple,
apple, pear, etc. banana pear
(5)
1 tbsp soft or mashed e.g. 1 slice melon 1 slice melon
carrot, courgette 4 strawberries/blackberries 6 grapes
75ml fruit juice* 1-2 tbsp vegetables or 2-3 tbsp vegetables or
small chopped salad small salad
150ml fruit juice* 150ml fruit juice*
1½ tbsp lentils

Milk and Dairy 3 dice-size pieces of cheese 4 dice-size pieces cheese 1 small matchbox size
(2-4) 2 tbsp yoghurt 2-3 tbsp yoghurt or custard cheese
100ml full fat milk 120ml full fat or semi 4 tbsp yoghurt or custard
skimmed milk 120ml full fat or semi
skimmed milk

Foods high in fat and/or ½ soft biscuit 1 biscuit 1 biscuit

sugar 3 tbsp jelly 4 tbsp jelly 5 tbsp jelly
(1-2) ½ small slice cake 1 small slice cake 1 small slice cake

*Fruit juice only counts for one portion irrespective of how much is taken

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