Extract from parents chatting with Marion Noble, Paediatric Dietician.

The chat discussions have been slightly changed to facilitate reading and protect privacy of the participants.

Marion Noble: I am here to chat about general nutrition and feeding problems and queries that you may have about your baby or toddler .

Marion Noble: I think in general we need to be careful that toddlers don?t have too much juice. Juices after all contain quite a lot of sugar and not a lot else. About 4-6 ounces of dilute juice a day- fresh juice diluted 1 in 10 with water. I think the main thing is not too much. Water and milk should be their main drinks.

Marion Noble: How old are the children?

Parent: They are 21 months Marion

Parent: I can?t get them to drink water and milk gets expensive when they drink all the time Marion Noble

Marion Noble: I am a little bit concerned of how much total milk they are drinking, we are generally looking for max 500mls per day at this age.

Parent: How many bottles would that be?

Marion Noble: We are talking about 3, 6 ounce bottles or 3 x 180ml cups.

Parent: Oh they have 3 to 4 9 oz bottles Marion

Marion Noble: Sugar doesn?t provide with anything but calories - empty calories, because there are no other nutrients at all.

Marion Noble: I think as well as what foods to start on it is useful to think about when we should start, as guidelines have changed in the last year to 18 months. The advice on timing now is that infants can get all the nutrition they need from breast milk or infant formula up to the age of 6 months. So if we start introducing solids at 6 months we are looking at starting with a little bit of rice based cereal, moving fairly rapidly to purees of veg and fruit. If we start at 6 months the progression of foods needs to be quicker than it used to be as we need to fairly rapidly introduce a good source of iron, usually done by introducing wheat based cereals and pureed meat such as lamb.

Marion Noble: Trying to get enough fruit and veg into three year olds is a perennial problem; the important thing is to keep offering them with as much variety as possible. There is an enormous range of different veg, root veg thinking about things like pumpkin, sweet potato, just something a little different and in fact if you have a 3 yr old who will try new veg I think a lot of other parents will be jealous! The child may or may not accept the new veg at that age, at 3 yrs they are probably more likely to accept them than they would have done than when they were 2. And the same thing applies to fruit - there is an enormous variety out there. Probably the most important thing in a child accepting a new food at this age is for them to see parents and siblings eating the food first.

Marion Noble: I would just ask first of all have you talked to your health visitor about talking to or getting in touch we a breast feeding advisor. Assuming that you need an alternative, I would suggest any of the standard infant formulas available would be suitable. At the present time we don?t feel that there is enough evidence about the small differences between these milks to recommend one over another, all infant formulas are very closely regulated in this country and must contain the correct nutrients within very strict parameters.

Parent: Marion: o.k. but in general would you say that breast feeding (if it works) is more recommended that providing infant formulas?

Marion Noble: absolutely, there is no doubt that breast milk is the ideal food for the vast majority of babies.

Parent: I?ve tried expressing milk but it is pretty exhausting...

Marion Noble: I would just say that breastfed babies mostly feed more often and this can be absolutely normal but tiring. Formula fed babies do tend to have longer between feeds and this reflects the fact that they are based on cow milk rather than human milk.

Marion Noble: could you please also specify the age of your child for Marion to answer your question.

Parent: He is two and a half years old

Marion Noble: problems with food acceptance can again be quite common around the age of 2 and 3 this is partly about independence I think the main thing is that you continue to set the rules. It is really important that you continue to offer regular meals as children who take regular meals in the long term tend to develop better eating habits than children who continually snack or graze. Eating with other members of the family is again important and I would say continue to offer a good range of foods. there is more information in dealing with this sort of problem on the pampers website under the learning centre, the article is called tempting toddler taste buds and I think it contains a lot of practical and sensible advice.

Marion Noble: I think it?s preferable to offer ordinary chips especially if they are homemade, but I realise but most people don?t do that these days. I think the smiley faces and waffles are both quite processed foods and in general, highly processed foods tend to be high in salt. If you are using pre-prepared oven chips, you could look at nutritional labelling and this will tell you how much fat and salt is in the product. We don't know if your little girl is growing well, but in general we are trying to avoid excessively high fat, high salt foods. The healthiest diet in general is the one that contains a good variety of foods from each of the food groups, so that we get enough protein foods, energy, fibre, minerals and vitamins. But the choice between chips, smiley faces and waffles doesn?t really add any nutritional benefit and of the 3 we would be looking for the least processed which may well be the chips. I would say though that it may be good to only offer these 2 or 3 times a week and also continue to offer potato in other forms even though it may not be eaten as if it is done in a non-confrontational way, she is more likely to eventually accept them, than if she is never offered them at all.

Parent: I do offer potatoes in other forms but she leaves the then I wonder if she is getting enough nutrition. As I said we have veg with most meals or beans, will she be ok if she doesn?t eat the potatoes? She wont drink milk either 4 the last 6mths. So I give her vitamins. She is growing fine

Marion Noble: The potato or carb part of her meal is providing a good calorie source and a little bit of vitamin C if she is eating any other fruit and veg then not eating potatoes is unlikely to lead to any nutrient deficiency. I think if she is not drinking milk that may actually be more of an issue. If she is growing well, particularly in height then it is unlikely that she is not getting enough calcium, is she eating other sources such as cheeses, yoghurts, milky puddings etc? If the answer is no, she may need a calcium supplement just to be on the safe side but again if she is growing well it is unlikely. On the Pampers website there is an article - "How can I help my son drink milk or get calcium from other sources? If you have a look at this it will give you and idea of how much yoghurts, cheese etc she might need to take, and also examples of non-milk based foods which contain

Marion Noble: No, I think a healthy mixed diet (sorry if that sounds a bit obvious!) I think the most important thing is to make sure she drinks enough fluid. We have just said that breast fed babies can feed very frequently, and sometimes mums are so tired they can forget to stop for regular meals and drinks. So partners can be really helpful in helping to provide meals and regular fluids.

Parent: What about foods to avoid?

Marion Noble: This is very individual, there are no rules for foods to avoid other than if you find that your baby has any adverse symptoms that you can link back to a particular food. There is a lot of anecdotal evidence on avoiding different foods, but I think we come back to avoiding anything that you have found actually upsets you baby.

Marion Noble: This is a really interesting question. In terms of whole peanuts, then the answer is certainly no. The advice is that whole peanuts should not be offered to children under 5yrs because of the danger of choking. If there is no history of allergy in either yours or his mum?s family then ground peanuts in foods may be acceptable.

Marion Noble: When did you start weaning? What stage is she in weaning?

Parent: She has been weaning for a month and a half now

Marion Noble: Just to expand a little bit on that, because your little girl is under 6 mths we would advise that you avoid wheat based cereals, and up until 6 mths, and that perhaps breakfast could be a rice based cereal with various types of pureed fruit.

Parent: Ok, thanks

Marion Noble: In general terms as when to wean again, the earliest date recommended for weaning these days is 17 weeks which is about when your daughter started. when we start at 17 weeks the whole process is a little bit slower and this is because one of the reasons for starting introducing foods other than milk to a babies diet is the fact that at about 6 months the store of iron in their liver, start to run out, so as we discussed earlier, if you start weaning at 6 months you need to go faster in terms of food introductions and you need to use iron containing foods such as wheat based cereals but if you start at 17 wks, then we would avoid wheat based cereals and other major proteins until the age of 6 months because we think that a younger babies gut is immature and may not cope well with them. By the time they get to 6 months, we think there is a benefit in the child being exposed to these foods.

Marion Noble: I thought it might be useful to go over the current recommendations again as there have been some changes in the last 18 months. The recommendation is that breast milk or infant formula can provide all the nutrition a child needs up to the age of 6 months, so that 6 months is recommended as the best time to start to introduce other foods. However, it is also recommended that weaning isn?t started before 17 weeks.

Marion Noble: This is another good question! I think this comes back to what we were saying about breast milk substitutes in that the composition of infant formulas is very closely regulated and they are very similar. Sometimes if a baby has a problem getting treatment for it can be delayed but trying a variety of similar milks, when it may be if there is a significant feeding problem, that it may need to be looked at by your GP, and a more specialised milk may be required.

Marion Noble: We may be looking at a constipation problem here and it may be that if his little gut is all bunged up that this is affecting his appetite. I am not sure how long this has been going on for, but the kind of foods that you would be hoping to encourage would be fruit and veg, any kind of beans, and wholemeal cereals but probably most important of all at this age is how much fluid he is taking. And this is probably one instance if it was difficult to get fruit and veg we might think about using some fruit juice. Depending on how bad the constipation is but if he is passing small hard balls it is more than likely that he is constipated in this case I would talk to your health visitor for more advice on suitable foods and fluids but also as to whether he needs some anti-constipation medication initially to clear him out and this may well help to improve his appetite.

Marion Noble: If your baby is passing a lot of wind with no ill effects, then this is not necessarily a problem it could be related to one or more foods in the diet. This is really a matter of trial and error to find out which. If the wind is causing a lot of pain then obviously it is much more of a problem and may be something that you want to talk to your health visitor about. But in general to answer your question, wind without pain can be perfectly normal but colic infers pain and distress in the infant.

Marion Noble: This problem is really quite common, children are programmed to want as much as much attention as possible from their parents and sometimes if they find that they get a lot more attention for not eating this can affect their behaviour. And the aim in this case as we have said before today is to try and ignore the behaviour you don?t want and give lots and lots of encouragement when you do get the behaviour you do want (you can go OTT with this) The other reason why a 3 yr old will eat in some circumstances and not others is to do with the fact that the greatest influence on whether they will eat a food or not is whether their peers are eating it. So if there are other children at the child minders eating the same food this may well be having a major effect this happens a lot in children of this age many mums will describe that foods a child will not eat at home they will happily eat at nursery. so just keep offering the variety of foods at home that you want and it helps if the child is eating with the rest of the family and if the grown ups present are eating that food at home.

Marion Noble: In general although there is a lot of anecdotal information about eggs and bananas causing constipation, it is something I come across very rarely, however, if you have found that giving these foods causes constipation in your child to the point where she has to have medication, then I think you are absolutely justified in ignoring them. I would just reiterate the importance of fluid intake in avoiding constipation, nutritionally as long as there are reasonable iron-sources in the diet and other fruits and veg are taken, and then I don?t think that there is any nutritional implication in avoiding both these foods.

Marion Noble: We've talked a little bit about this already today and if we are looking at the formulas that are suitable from birth then I don?t believe that we have enough evidence to recommend one over another. We've talked about the fact that the nutrient of all infant formulas are very closely regulated the really differences come in thinking about follow on milks but I would say that if your child is on standard infant formula and at 6 months starts weaning and by 12mnths is having a good range of weaning foods including iron containing foods then I would suggests that you continue with the infant formula you are on form now until 12mnths of age when you would consider changing onto full fat doorstep cows milk because milk is a much less important part of a child?s diet at this stage

Marion Noble: A summary will be posted and we have covered this question previously today. However there is a really good article on the Pampers website called ?Tempting toddler taste buds?, which contains lots of practical and sensible advice.

Marion Noble: Thank you for all your questions, we have covered a really good range and hopefully come up with some practical strategies for dealing with some of the issues covered.

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