NHD Focus on Paediatric Nutrition by NH Publishing Ltd

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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

May 2017: Issue 124

PAEDIATRIC NUTRITION: A HEALTHY START FOCUS

ON Paediatrics

Articles from our experts on infant weaning, formula milks, toddler snacks and nutrition in schools.

FROM THE EDITOR Emma Coates - NHD Editor

Welcome to our second Focus on supplement. Here we discuss the importance of getting a healthy nutritional start for our infant and child population. Infants benefit greatly from optimal nutrition within in the first 1,000 days of life. This ‘window of opportunity’ defines health for the rest of the child’s life. Improving nutrition and preventing malnutrition during this critical window of development can ‘program weight regulation and brain development’.1 We start with infant formula milk with Dr Emma Derbyshire examining formula in relation to full cream milk fats. Maeve Hanan RD then shares her thoughts on the nutritional content of follow-on formula, including the current evidence and advice for their use. The introduction of solid foods into an infant’s diet is often an exciting yet confusing time for many parents and healthcare professionals. Kate Roberts RD discusses the evidence base for complementary feeding, whilst clarifying the current recommendations and advice. Food and diet trends have become big news and big business, as we all become ever more aware of the benefits of tailored nutrition across the lifespan. The infant and toddler market is no exception. In Emma Derbyshire’s second article, she takes a closer look at the growing infant and toddler snack market, giving us an evaluation of the relevance and nutritional content of current products. Finally, nutrition in schools rounds up our Paediatric supplement. Maeve Hanan takes us through the various guidelines and recommendations which aim to improve nutrition and health promotion in schools. Enjoy the read. Emma Reference 1 Bhutta ZA. Early nutrition and adult outcomes: Pieces of the puzzle. [Comment] Lancet, 382 (9891) (2013), pp 486-487

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Contents

FOCUS ON PAEDIATRICS 3

Full cream milk in infant formula The latest innovations

9 FOLLOW-ON FORMULA Nutritional content and value 12 Complementary feeding An evidence-based guide

15 INFANT & TODDLER SNACK PRODUCTS A nutritional profile 18 Nutrition in schools Encouraging healthy food choices Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson

Publishing Assistant Katie Dennis Design Heather Dewhurst

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

PAEDIATRIC SUPPLEMENT

INFANT FORMULA CONTAINING FULL CREAM MILK FATS: LATEST INNOVATIONS Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government, publishers and PR agencies. She is an avid writer for scientific journals and media. Her specialist areas are public health nutrition, maternal and child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

For full article references please email info@ networkhealth group.co.uk

The benefits of breastfeeding are well established, with exclusive breastfeeding recommended for up to six months of age. Presently, in Great Britain, less than 17% of women comply with these guidelines and manage to breastfeed ‘exclusively’ for the full six months. In circumstances where breastfeeding may not be possible, solely adequate, or suitable, closely matched alternatives are needed. This article aims to discuss the nutritional profile of infant formula that uses full-cream milk fats (whole cows’ milk) and explains how these products are evolving and integrating the latest science. It is widely acknowledged that breastfeeding is best, having many short and long-term benefits for both mother and child.1 The World Health Organisation (WHO) advises that ‘exclusive breastfeeding is recommended for up to six months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond’.2 The colostrum in particular (the yellowish sticky fluid produced after birth) is regarded as the perfect food for the newborn and should be introduced within the first hour after birth.2 Unfortunately, through no fault of their own, many women are not able

to breastfeed. There is evidence that long labours, maternal exhaustion and stress due to traumatic deliveries can all lead to delayed lactogenesis.3 Other work has shown that women delivering by emergency C-section have a higher proportion of breastfeeding difficulties (41%) compared to those delivering vaginally (29%).4 Medical conditions, such as tongue tie (ankyloglossia), can also affect an infant’s ability to latch on, leading to breastfeeding problems.5 A summary of studies investigating obstacles to breastfeeding is shown in Table 1. The World Breastfeeding Trends Initiative (WBFTi), supported by the Lactation Consultants of Great Britain, provides useful insights into patterns of infant feeding.6 As shown in Figure 1 overleaf, patterns of breastfeeding vary across Great Britain. Data from the WBFTi (2016) shows that three out of five women (60%) initially breastfeed within one hour of giving birth. However, by six months less than two out of 10

Table 1: Key obstacles to breastfeeding Obstacle Emergency C-section Employment and early return to work Infant tongue tie (ankyloglossia) Long labours, maternal exhaustion and stress Pain, difficulty latching on, relentlessness of early infant feeding Maternal obesity and related difficulties Sibling jealousy www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Figure 1: Initiation and rates of exclusive breastfeeding for six months (% of women)

(17%) women in England breastfeed exclusively, with lower rates of 10 and 13% in Northern Ireland and Wales, respectively. Furthermore, the median duration of breastfeeding is three months in England, five days in Northern Ireland, six weeks in Scotland and just over two weeks in Wales (Figure 2).

Months

Figure 2: Median duration of breastfeeding (months)

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In instances where breastfeeding may not be possible, adequate or suitable, other options are needed.7 Infant formula that mimics the nutritional composition of breastmilk, particularly its fat composition, may be the next best alternative to provide nutrition and nurture to the infant.8 A recent study showed that of 81%

Table 2: Nutritional profile of milks (per 100ml)

Water g Energy Kcal Fat g Saturated fat g Carbohydrate g Protein g Vitamins Biotin mcg Folate mcg Niacin mg Retinol mcg Vitamin B1 mg Vitamin B12 mcg Vitamin B2 mg Vitamin B6 mg Vitamin C mg Vitamin E mg Vitamin K mcg Inorganics Calcium mg Chloride mg Copper mg Iodine mcg Iron mg Magnesium mg Phosphorous mg Potassium mg Selenium mcg Sodium mg Zinc mg

Milk, whole, pasteurised, average 87.6 63 3.6 2.3 4.6 3.4

Milk, semi-skimmed, pasteurised, average 89.4 46 1.7 1.1 4.7 3.5

Human milk, mature

2.5 8 0.2 36 0.03 0.9 0.23 0.06 2 0.06 0.6

3 9 0.1 19 0.03 0.9 0.24 0.06 2 0.04 NR

0.7 5 0.2 58 0.02 Tr 0.03 0.01 4 0.34 NR

120 89 Tr 31 0.02 10 96 157 1 42 0.5

125 87 Tr 30 0.03 10 96 162 1 44 0.5

34 42 0.04 7 0.07 3 15 58 1 15 0.3

87.1 69 4.1 1.9 7.2 1.3

Source: CoFID (2015)

of mothers using infant formula, 69% chose to feed their infants cows’ milk formula.9 WHOLE COWS’ MILK

As shown in Table 2, the fat content of whole cows’ milk is closely aligned with that of human milk. Studies show that milk fat contains around 400 different fatty acids, making it the most complex of all natural fats.10,11 Due to the natural presence of fats in whole cows’ milk, fewer manufactured vegetable oils need to be added to infant formulas using this as a base. Recently, the use of vegetable oils in formulas has been questioned, as these can influence

the balance of palmitic acid (16:0) which is an essential component of infant tissue lipids.12 It has also been associated with reduced fat and calcium absorption and harder stools when used in infant formulas,13 and its use is questionably ethical, namely due to wide scale deforestation.14 Whole cows’ milk is also a good provider of B vitamins, including B2 (riboflavin) and B12 and the minerals iodine, potassium and phosphorous (Table 2). Research has shown that the bioavailability of vitamin B12 in cows’ milk is substantially higher than equivalent amounts of cyanocobalamin, the synthetic form of this vitamin.15 Milk is also an important source of www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT choline, an essential nutrient that contributes to the growth and development of newborns.16 Cows’ milk also contains more L-carnitine than human milk which plays a central role in energy production, alongside being concentrated in tissues such as skeletal and cardiac muscle.17 Taken together, the range of nutrients present in whole cows’ milk provides a good base for infant formulas, though iron levels are lower than needed. At this point it should be considered that infant formulas are different to liquid cows’ milk in that they are fortified with iron and other nutrients, including vitamin D. The shortfalls in iron are partly why liquid cows’ milk is not advised for the first 12 months of life.18 Cows’ milk, however, tends to be associated with cows’ milk allergy (CMA). Findings from the latest EUROPREVALL Study (The prevalence, cost and basis of food allergy across Europe) found that <1% of children up to the age of two years had confirmed CMA. The diagnosis of CMA in this important study was tested using gold standard diagnostic procedures.19 MILK FATS

Human milk fat naturally contains palmitic acid that is esterified to the beta-position of triglycerides (an sn-2 bond), with evidence that this form favourably influences fatty acid metabolism and calcium absorption and improves bone matrix, stool consistency and the gut microbiome.20 The sn-2 bond is also regarded as being particularly important in the regulation of fat digestion and absorption.21 Presently, most supplemental formulas using vegetable oils as a main fat source contain palmitic acid with sn-1 and sn-3 bonds located at the external or alphaposition, which may impact on intestinal fat absorption.22,23 Formulas using dairy fat tend to contain more palmitic acid that is esterified in the sn2 position.24 Since the middle of the 20th century, cows’ milk fat has progressively been removed from infant formulas and replaced with vegetable oils.24 Latest evidence, however, indicates that dairy fat blended with a lower level of vegetable oils may be the best way to mimic the composition, structure and physiological properties of human breast milk oils.24 The 6

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combined use of different lipid sources also helps to balance out proportions of fatty acids, especially lauric, myristic and palmitic acid,25 as well as providing palmitic acid mainly in the esterified sn2 position of triglycerides.24 Whole cows’ milk fat also provides a range of lipophilic microconstituents. These include the vitamins A, D, E and K, carotenoids and phytosterols.26 A spectrum of bioactive components are also present in milk fat, including lipophilic antioxidants such as conjugated linoleic acid (CLA), coenzyme Q10 and phospholipids, with milk fat being regarded at the most easily digested fat in the human diet.11 CLA, in particular, has drawn particular attention for its biological activities, including its ability to modulate immune and inflammatory responses.27 It has recently been proposed that an ideal docosahexaenoic acid (DHA) target should be established for breast milk, with the view that this should be 0.3% or 1.0% of milk fatty acids.28 Koletzo and colleagues29 have also recommended that, when breastfeeding is not possible, infant formulas should provide DHA between 0.2 and 0.5 weight percent of total fat, with the minimum amount of Arachidonic Acid (ARA) equivalent to the contents of DHA being used. Recently, it has been put forward that both DHA and ARA should be included in infant formula, as breastfed infants obtain both of these fatty acids.30 With regard to trans fats, these are naturally present in whole cows’ milk but also present in breast milk via dietary transfer.31,32 Current opinion suggests that adding complex lipids and milk fat globule (MFG) membranes to vegetable oil-based infant formula could help to enhance infant development and reduce infections.33 For example, human fat contains an array of lipid component present as MFG, with a core containing triglycerides (98% of total lipids), surrounded by a MFG.24 Consequently, cows’ whole milk formulas have the advantage over those using semi-skimmed milk in that cows’ milk already contains complex natural fats and around 400 different fatty acids.10 This means that fewer processed vegetable-oils or other complex lipids need to be added.

Breastfeeding support and interventions should continue to be provided, especially as levels of ‘exclusive’ breastfeeding are so low.

IRON

There have been concerns about the low iron content of cows’ milk, with particular reference to iron deficiency (ID) risk in infants and toddlers.34 However, the iron content of human milk is also typically low, with the theory that an infant’s iron stores should be accumulated in pregnancy.35 Whilst iron is needed for infant neurodevelopment,36 excess iron may promote the growth of pathogenic iron requiring bacteria,35 indicating the importance of balance. The Global Standard for the composition of infant formula advises that the iron content of formula based on cows’ milk protein and protein hydrolysate should be a minimum of 0.3mg per 100kcal and maximum of 1.3mg per 100kcal.37 Revised guidelines relating to iron intakes in babies and children up to three years of age, have been issued in compliance with article 14 of the European Commission Regulation. This ensures that infant formula and follow-on formulae contain sufficient levels of iron, ranging from 0.6mg/100kcals to 2.00mg/100kcals, to support the formation of haemoglobin and red blood cells and a normal functioning immune system.38,39,40 VITAMIN D

Cows obtain vitamin D from both their diet and skin UVB exposure, with the vitamin D status of the cow impacting on the vitamin D content of milk produced in much the same way as human breast milk.41 Whilst there is great potential to further optimise the vitamin D content of cows’ milk, cows’ milk formulas are fortified to ensure that infants obtain suitable levels of vitamin D. The global standard for the composition of infant formula advised that infant formula contained a minimum of of 1µg and maximum of 2.5µg vitamin D per 100kcal.37

Health claims relating to the contribution of vitamin D to normal development of teeth and bones, have been formally approved and considered appropriate for infants and young children from birth to three years.42 Recently, the UK Scientific Advisory Committee on Nutrition report on vitamin D advised a safe daily intake of between 8.5-10μg/day for ages 0 up to one year (including exclusively breastfed and partially breastfed infants, from birth); and 10μg/day for ages one up to four years, although data was not sufficient to set Reference Nutrient Intakes.43 Amongst a sample of Dutch infants, median vitamin D intakes were 16-22µg/day for infants aged 0 to six months (increasing with age) and 13-21µg/day for infants aged seven to 19months (decreasing with age), indicating that a combination of infant formula, (fortified) foods and supplements was successful in achieving suitable intakes of vitamin D.44 DISCUSSION

Taking the latest evidence on board, breastfeeding is the gold standard when it comes to infant feeding and should be undertaken for at least six months exclusively.2 However, in reality, for physiological or other reasons, these guidelines are not being followed. In fact, latest data across Great Britain shows that less than one in five (20%) of women feed their infants exclusively for the first six months.6 Whilst interventions can clearly be put into place to improve rates of breastfeeding, other options also need to be provided. Whole cows’ milk is a good provider of nutrients, especially B2 (riboflavin), B12, iodine, potassium and phosphorous,45 along with choline16 and L-carnitine.17 Milk lipids in general are attracting much interest at present, due to the presence of bioactive compounds in the lipid fraction - this includes omega-3 and 6 www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT polyunsaturated fatty acids, conjugated linoleic acid, short chain fatty acids, gangliosides and phospholipids.46 Furthermore, it is coming to light that cows’ milk lipids and milk fat membrane extracts better mimic human milk structure and composition, yet few infant formulas use these, as they are more expensive than vegetable lipids.47 Subsequently, more recent evidence suggests that adding complex lipids and milk fat globules to vegetable-oil based infant formulas could help to support infant development and reduce infection risk.33 Animal studies indicate that grass-fed cows produce milk with an improved fatty acid profile. For example, a recent study has found that Holstein cows fed on cool-season pastures produce whole milk with a higher omega-3 and CLA content than those fed on pearl millet.48 Other work has also shown that pasture-fed cows, i.e. fed outdoors on grass and clover, produce milk containing significantly higher levels of saturated and unsaturated fatty acids, with more than a two-fold increase in CLA compared with milk produced from cattle fed indoors on a total mixed ration diet.49 Augmenting milk microconstituents by means of animal nutrition, rather than milk fortification, also helps to safeguard animal health.26 Formulas using whole cows’ milk also have potential to support the British dairy industry.

The British dairy industry is under pressure, with many dairy farmers expected to leave the industry, as they cannot continue to produce milk at a loss. This is largely due to increasing UK and EU supplies coupled with a stagnant global market.50 In New Zealand, infant formula is regarded as an ‘export superstar’ and has played a significant role in supporting the dairy industry which has now become a great success.51 Whilst breastfeeding should continue to be supported first and foremost, it should also be considered that alternatives are needed and the British dairy industry can play a role in providing these. CONCLUSIONS

In summary, whilst breastfeeding is regarded as the best way to feed infants, this is not always possible for a host of different reasons. Breastfeeding support and interventions should continue to be provided, especially as levels of ‘exclusive’ breastfeeding are so low. However, whilst the benefits of breastfeeding are well recognised, it should also be appreciated that other options are needed for women who cannot breastfeed through no fault of their own. In these instances, British full cream formulas provide an alternative option. These provide a good nutrient base, meaning that only subtle levels of fortification and fewer manufactured vegetable oils are needed.

Key points •

Exclusive breastfeeding is recommended for up to six months of age, as advised by the World Health Organisation (WHO.

•

Presently, less than 17% of women in Great Britain feed infants exclusively for the recommended sixmonth duration.

•

Cessation of breastfeeding appears to be attributed to a host of different reasons, including physiological and medical reasons.

•

In cases where breastfeeding is not possible, solely adequate, or suitable, closely matched alternatives are needed.

•

Full-cream milk fat infant formula provides an excellent nutrient base and spectrum of fatty acids.

•

There is growing evidence that lipid sources need to be carefully selected to better mimic breast milk, which includes the potential use of dairy fat.

Conflict of Interest This review was supported by Kendal Nutricare Ltd. The article was written independently and its content reflects the opinion of the author only.

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PAEDIATRIC SUPPLEMENT

FOLLOW-ON FORMULA Maeve Hanan Registered Dietitian, City Hospitals Sunderland, NHS

Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

For full article references please email info@ networkhealth group.co.uk

Follow-on formula can be used with infants from the age of six months alongside appropriate complementary feeding.1 Although there are some nutritional differences between infant formula and follow-on formula, for the majority of infants there is no benefit from switching to a follow-on formula.2 There has been a considerable amount of controversy surrounding the advertising practices related to follow-on formula; for example, in the UK it is illegal to advertise infant formula to the general public, however the advertising of follow-on formula is permitted.3 The World Health Organisation (WHO)4 and the UK Department of Health (DH)1 report that followon formula is unnecessary and an unsuitable substitute for breastmilk or first infant milk. Specifically, the UK government advises that ‘breast milk is the best form of nutrition for infants and exclusive breastfeeding is recommended for around the first six months of an infant’s life*’ and, unless advised by a health professional, ‘first milk’ is the only suitable alternative for breastmilk and ‘the only type of formula an infant requires until the age of 12 months, when cows’ milk can be introduced as a main drink into the diet’. *However the British Dietetic Association (BDA)5 and the European Society for Paediatric Gastroenterology,

Hepatology, and Nutrition (ESPGHAN)6 advise that complementary feeding can be introduced from four to six months of age and the Scientific Advisory Committee on Nutrition (SACN)7 is currently working on updating UK recommendations on complementary feeding.

UK STATISTICS

As displayed in Table 1, the UK Diet and Nutrition Survey of Infants and Young Children, 20111 identified that although follow-on milk was most commonly given to infants aged seven to 11 months, 32% of babies aged four to six months were also given follow-on formula. Furthermore, this survey found that by 10 to 11 months, 69% of all mothers had given their baby follow-on formula at some stage; which is an increase from 53% in 2005. SACN’s analysis of the 2005 UK Infant Feeding Survey8 found that younger mothers, those from lower socioeconomic groups and those with lower educational levels were the least likely to try to continue breastfeeding, were more likely to use follow-on formula and were more likely to provide this at an earlier age. SACN also reported that at four to six months, the main reasons given for switching to follow-on formula included: • past experience using this with previous children (23%); • believing it was better for the baby as it provides more nutrients (20%); • thinking that the baby was still hungry after being fed ordinary infant formula (18%);

Table 1: Use of follow-on formula in infants Age group

Percentage use of follow-on formula

4 to 6 months

32%

7 to 9 months

56%

10 to 11 months

59%

12 to 18 months

16% www.NHDmag.com April 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Table 2: Nutritional comparison per 100ml of breast milk, infant formula and follow-on formula11,12 Nutrient

RNI for infants 6-12 months**

Breast milk per 100ml

Infant formula per 100ml

Follow-on formula per 100ml

Energy (kcal)

710-960

60-70

Protein (g)

12.7-14.9

1.3

1.8-3

1.8-3.5

Fat (g)

approx. 28-37 (i.e. 35% total energy)

4.1

4.4-6

4-6

Carbohydrate (g)

approx 89-120 (i.e. 50% total energy)

7.2

9-14

Iron (mg)

4.3-7.8

0.07

0.3-1.3

0.6-2

Calcium (mg)

524

50-140

Sodium (mg)

276-345

20-60

Vitamin A (µg)

350

60-180

Vitamin D (µg)

8.5-10 (safe intake)

0.2-3.1

1-2.5

1-3

Vitamin C (mg)

10-30

Thiamine (mg)

0.18-0.23

0.02

0.06-0.3

Riboflavin (mg)

0.4

0.03

0.08-0.4

Niacin (mg)

4-5

0.2

0.3-1.5

Vitamin B6 (mg)

0.2-0.4

0.01

0.035-0.175

Linoleic acid (mg)

>1% total energy13

560

300-1200

Linolenic acid (mg)

>0.2% total energy

**This is a combination of the nutritional requirements of age groups 4-6 months, 7-9 months and 10-12 months from the Great Ormond Street guide Nutritional Requirements14; this is not suitable for devising nutritional requirements.

• recommendations from doctors or health visitors (22%). NUTRITIONAL CONTENT

Follow-on formula is often advertised for use by ‘hungrier babies’ as it is casein based which may take longer to digest than whey based formulas; however, this claim is not supported by the evidence base.8 Follow-on formulas can be higher in protein, energy, calcium, iron and other micronutrients compared to breast milk.9 According to the American Academy of Paediatrics Committee on Nutrition and the Australian National Health and Medical Research Council, there are no established advantages of follow-on formula over breast milk in relation to changes in its fat, protein, carbohydrate, calcium and sodium composition.10 WHO has highlighted that follow-on formula can be higher in protein than those recommended for adequate growth and development of infants and young children.4 Research is emerging that 10

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most infants in high income countries exceed their protein requirements and a higher protein intake in early life may be associated with a higher risk of obesity in later life.6 For this reason and also because the current minimum protein level permitted in follow-on formula (1.8g/100kcal) remains higher than that found in breast milk, the European Food Safety Authority (EFSA) has recently completed a public consultation to consider lowering this minimum level to 1.6g/100kcal and have also lowered the maximum permitted protein level from 3.0 to 2.5g/100kcal.6 Follow-on formulas may be useful for those with low iron levels, or a poor weaning diet over the age of six months; however, the majority of infants won’t need the additional iron that these formulas provide if they have an adequate weaning diet.9,10 There is mixed evidence from studies which compared iron supplemented follow-on formulas with cognitive outcomes and also dietary iron intake in infants and cognitive outcomes.6

PAEDIATRIC

It is clear that the follow-on formula market is thriving, despite the limited supporting evidence for their nutritional use; There is some evidence that follow-on formula supplemented with DHA (an omega-3 fatty acid which is included in most infant formulas in the UK) may improve short-term visual function in infants, which is important, as some European infants and young children may be at risk of a low omega-3 intake. However, genotype and fish intake also play a role in DHA status and studies using DHA-enriched egg yolk as part of complementary feeding have also been shown to increase DHA levels.6 ADVERTISING LAW

Numerous studies have found that the labelling and marketing of follow-on formula can persuade parents to switch from breastfeeding to followon formula unnecessarily when their baby reaches six months4,8,16-17 and that the advertising of follow-on formula may be contributing to the low levels of breastfeeding found in the UK.8 (The 2010 infant feeding survey reported: 81% breastfeeding initiation, 69% breastfeeding at one week, only 34% breastfeeding at six months.18) Follow-on formula can also be confused with first infant formula; SACN (2008) identified that this is most likely to occur in lower socioeconomic groups and in general that ‘many mothers are unclear about the distinction between the different types of formula’.2,8 Therefore, in 2010 the World Health Assembly Resolution appealed to ‘infant food manufacturers and distributors to comply fully with their responsibilities under the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly Resolutions’, as these marketing strategies were undermining optimal infant feeding.4,15 The UK government now mandate that the labelling of follow-on formula must state the following:3,19

• ‘The product is suitable only for particular nutritional use by infants over the age of six months.’ • ‘The product should form only part of a diversified diet.’ • ‘Infant formula and follow-on formula shall be labelled in such a way that it enables consumers to make a clear distinction between such products so as to avoid any risk of confusion between infant formula and follow-on formula, (including the age range in an appropriate font size).’ • ‘The superiority of breastfeeding via an ‘Important Notice’.’ Although it is illegal to advertise or promote infant formula (with the exception of information for a scientific or trade publication), there are no restrictions on the promotion of follow-on formula beyond the rules related to packaging described above; however more stringent promotion laws have been called for by SACN in order to reduce the amount of parents switching their babies on to follow-on formula at a young age.8,19 CONCLUSION

It is clear that the follow-on formula market is thriving, despite the limited supporting evidence for their nutritional use; with the exception of a potential benefit for some infants over six months with anaemia or an inadequate weaning diet. Although there are clear labelling laws related to this type of formula in the UK, the fact that there are few advertising restrictions increases the risk that infants may be inappropriately switched to a follow-on formula. As health professionals it is our role to remain consistent with the message that ‘breast is best’ until at least 12 months and where formula is used, there is no benefit to switching from infant formula to a follow-on formula for the majority of infants. www.NHDmag.com April 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT

COMPLEMENTARY FEEDING: THE EVIDENCEBASED GUIDE TO WHAT, WHEN AND HOW Kate Roberts Freelance Dietitian, Kate Roberts Nutrition

Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children having previously working in the NHS. Her specialities are Diabetes and Allergies.

In 2002, the World Health Organisation (WHO)1 recommended that mothers should breastfeed exclusively until six months and then begin complementary feeding. This is what the majority of mothers in the UK are being advised.2 But is this the correct message? Are people following the advice? What can and should dietitians be recommending? Complementary feeding is the period when infants no longer get all the nutrients they need via breast milk or infant formula, therefore, other foods and liquids need to be introduced.1 It can also be called weaning, but this term can be confused with weaning off breastmilk onto infant formula. The overall aim of complementary feeding is for children to be getting the right nutrients at the right time and eventually eating more or less the same as the rest of their family by the age of one.1 New guidelines from the Scientific Advisory Committee on Nutrition (SACN) have recommended that Vitamin D should be supplemented in breastfed babies from birth.7 Nutrients which are needed in addition to breast milk and formula from four months are iron and zinc.11 There have been some excellent studies recently which have changed our outlook on complementary feeding. Here, I summarise the main points of each. Learning early about peanuts (LEAP) study 20153 This landmark study found that the introduction of peanuts to high risk infants reduced the incidence of peanut allergy. The LEAP study found that only 3% of the children who consumed peanuts between the ages of four to 11 months developed a peanut allergy by the age of five, compared to 17% in the group that avoided them. This trial was a game-changer in the advice that should be given to new parents, as, for decades, healthcare professionals

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had been recommending that allergens should be avoided. Enquiring about tolerance (EAT) 20164 In this study, six allergenic foods were introduced to breastfed infants from three months of age. The allergens included: peanut, cooked egg, cows’ milk, sesame, whitefish, and wheat. Although they were unable to statistically prove that introducing these foods reduced the incidence of allergy, they did prove that introducing them was safe; there were no cases of anaphylaxis and doing so did not adversely affect growth. The study did indicate that reducing the risk of allergy was dose-dependent. When it was strictly adhered to, there was a significant reduction in the development of allergies. Canadian Healthy Infant Longitudinal Development (CHILD) Study, 20165 This Canadian study included prospective questionnaires and skin prick testing, specifically looking at cows’ milk, egg and peanut. It found that exclusive breastfeeding up to six months did not affect the sensitisation of foods apart from cows’ milk. It did find that there was benefit to introducing the three allergens before the age of one. Following these studies, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition released a position paper in early 2017 on Complementary Feeding.6

I have based the following recommendations on the evidence above, as well as recommendations from ESPGHAN. DO PEOPLE FOLLOW THE CURRENT GUIDANCE?

Well, the short answer is no. Not all mothers can or want to exclusively breastfeed until six months for a variety of reasons. In the UK in 2010, 75% of parents had already introduced food by five months and only one in 100 mothers exclusively breastfed until six months.8 ESPGHAN suggests promoting exclusive breastfeeding until 17 weeks and having six months as a goal.6 WHEN CAN COMPLEMENTARY FOODS START TO BE INTRODUCED?

By 17 weeks infants possess the gastrointestinal and renal function to cope with complementary food.6 The necessary motor skills are developed between four to six months. It is actually more beneficial for acceptance of flavours and textures and avoidance of allergy to start complementary feeding early, somewhere between four to six months (but not before 17 weeks).6 It is good to start introducing solids as soon as the infant is ready. Parents should not delay the introduction of complementary foods past six months (26 weeks). There is, however, some confusion, as many healthcare professionals recommend that parents wait until six months unless there is a particular need. It is important to try and communicate with healthcare professionals in your wider multidisciplinary team to advise them of what you are advising and why. Signs that an infant is ready for complementary food:2 • Can hold their head up • Can bring their fingers to their mouth • Showing interest in food

HOW SHOULD COMPLEMENTARY FEEDING BEGIN?

Methods 1. Traditional: spoon feeding Benefits: • It’s an easy way to provide the infant with lots of new flavours. • Parents feel confident that the infant is eating. Potential risks: • Parents could give the infant the amount they think is right and not give the child the chance to stop when they are full. This can lead to children losing their satiety signals and may even be linked to obesity.12 • Purees can often be a mixture of different foods and infants will, therefore, not identify different flavours and what they are eating. 2. Baby-led weaning Benefits: • Infants see what food they are eating • Infants only eat what they want • Convenient • Eating the same as the whole family Potential risks: • Choking • Not getting enough to eat • Not getting enough iron Things to remember with baby-led weaning: • Avoid foods that are easy to choke on coin shaped foods (like slices of carrot and chopped sausage), grapes and raw apple which breaks off easily. • Encourage an iron-rich source at every meal time. • Ensure that baby is getting a high-energy component to every meal.9

Table 1: Traditional complementary feeding stages10 1

Around six months

Thicker consistency with some lumps; soft finger foods can also be introduced at this stage

Nine to 12 months

Mashed, chopped, minced consistency; more finger foods

12 months and older

Mashed, chopped family foods and a variety of finger foods

• Fruit and vegetables • Rice, pasta, potatoes, yam, bread and cereals • Meat, fish, pulses and eggs • Yoghurt, custard and cheese

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PAEDIATRIC SUPPLEMENT Table 2: Introducing allergenic foods and other nutrients Food/Nutrient Added sugar and salt Iron Gluten

Peanuts

Other allergens (such as cows’ milk, soy, egg etc) Honey

When they should be introduced Avoid in any complementary foods and drinks There is a high demand for iron in infants over six months, especially in breastfed babies; therefore, iron-rich foods should be encouraged. It is safe to introduce gluten after four months, it is not linked to an increase of incidence of coeliac disease or Type 1 diabetes. Large quantities, however, should be avoided. Infants who have severe eczema and/or egg allergy) should check with an ‘appropriately trained healthcare professional’ before having nuts. This may mean that they need to undergo skin prick testing and supervised introduction of peanuts. If the child has mild to moderate eczema, currently it is suggested that peanuts are introduced from six months of age. For those who do not have eczema, peanuts can be introduced as soon as some basic complementary foods have been introduced. They all may be introduced as soon as complementary feeding commences, unless diagnosed as having an allergy. Avoid until after 12 months.

A mixture of both would ensure the benefits of both methods. It is important that health professionals manage expectations of complementary feeding; it can be messy and frustrating when infants pull faces and refuse the food that has taken hours to prepare. Parents need to be aware that it may not be easy; as with every other part of parenting, you can never plan for how babies are going to react! THE CONTENT OF COMPLEMENTARY FOOD

A healthy diet should be encouraged from the start, with a focus on introducing a wide range of foods, especially bitter ones such as green vegetables. Infants may pull a face when trying a lot of foods for the first time; this is a natural reaction to a new flavour and does not necessarily indicate disgust. The key should always be to offer new foods multiple times which will help children to accept different flavours.

CONCLUSION

Dietitians can now recommend introducing complementary foods as soon as the infant is ready after 17 weeks, including allergenic foods. If a baby is at high risk of peanut allergy, it is essential to refer to an allergy team before commencing peanut-based foods. It is up to parents what method of complementary feeding style they use. A mixture of both traditional and baby-led weaning can be encouraged; in this way, parents are able to introduce flavours and allergens in a timely manner. However, they do need to watch for signs that their infants are full so they do not overfeed when using a spoon. From six months they can start letting their baby take control with finger foods and enjoy the benefits of baby-led weaning whilst continuing to introduce wider flavours and textures.

References 1 World Health Organisation (WHO) (2002). Complementary Feeding. Report of the Global Consultation. Geneva. 10-13 December 2001. Summary of Guiding Principles. http://apps.who.int/iris/bitstream/10665/42739/1/924154614X.pdf?ua=1 Accessed March 10, 2017 2 www.nhs.uk/Conditions/pregnancy-and-baby/Pages/solid-foods-weaning.aspx 3 Du Toit, G et al (2015). Randomised Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813 February 26, 2015 DOI: 10.1056/NEJMoa1414850 4 Perkin MR et al (2016). Randomised Trial of Introduction of Allergenic Foods in Breastfed Infants. N Engl J Med 2016; 374:1733-1743 May 5, 2016 DOI: 10.1056/NEJMoa1514210 5 Tran MM et al (2016) The Effects of Infant Feeding Practices on Food Sensitisation in a Canadian Birth Cohort. Am J Respir Crit Care Med 193; 2016: A6694 www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A6694 6 Fewtrell M et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. JPGN, Vol 64, Number 1, January 2017 7 Scientific Advisory Committee on Nutrition (2016). Vitamin D and Health. www.gov.uk/government/groups/scientific-advisory-committee-on-nutrition 8 McAndrew F et al (2012). Infant Feeding Survey 2010. London, ONS: The Information Centre for Health and Social Care. 9 Daniels L et al. Baby-Led Introduction to SolidS (BLISS) study: a randomised control trial of a baby-led approach to complementary feeding. http:// bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0491-8 10 Table from: www.bda.uk.com/foodfacts/WeaningYourChild.pdf 11 Thomas B and Bishop J (2007). Manual of Dietetic Practice. Blackwell Publishing Ltd, Oxford 12 Townsend E, Pitchford NJ. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a casecontrolled sample. BMJ Open 2012; 2: e000298. doi:10.1136/bmjopen-2011-000298

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PAEDIATRIC SUPPLEMENT

Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government, publishers and PR agencies. She is an avid writer for scientific journals and media. Her specialist areas are public health nutrition, maternal and child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

For full article references please email info@ networkhealth group.co.uk

THE NUTRITIONAL PROFILE OF INFANT AND TODDLER SNACK PRODUCTS The infant and toddler snack market is rapidly expanding, with an increased demand for specialist products in this important life-stage. This article, summarising recent analysis by Dr Emma Derbyshire, provides a nutritional evaluation of UK infant and toddler snack foods. This current analysis evaluates the nutritional profile of 98 snack products currently available in the UK typically found in supermarkets and pharmaceutical stores for this life-stage. Findings showed that fruit-based snacks dominate the market, although some vegetable-based products are beginning to emerge. Most products (48.5%) had thiamine on their nutrition label yet overlook nutrients where shortfalls are evident (vitamin D, iron). This paper highlights that there is still much work to be done in this important and growing sector. It is becoming increasingly apparent that nutrition in the early years is central to later health.1 The early years period also falls within the first 1,000 days of life (from conception to the second birthday), which is regarded as being a critical window of opportunity to optimise a child’s health.2 A nutritional analysis of commercial infant and toddler foods sold in the United States which included snacks, found them to be particularly high in sugar and sodium.3 Snacks are typically defined as ‘eating occasions between meals’.4 Amongst young children, a routine of three meals and two snacks a day is a useful benchmark to follow.5 It is, however, increasingly being recognised that the trend of ‘snackification’ (eating on the go) is showing no signs of subsiding.6 Whilst this trend is flourishing amongst adults, it also appears to be creeping in within the infant/toddler market. Bearing this

in mind, it is critically important that products available are appropriate in terms of flavour exposures and their nutritional profile. METHODS

Data collection Proportions of declared energy (kJ), energy (kcal), protein (g), carbohydrate (g), total sugar (g), total fat (g), saturated fat (g), fibre (g), salt (g) and sodium (g) content were examined along with the presence on additional micronutrients on the food label. Where sugars were not used to sweeten foods, the main source of sweetness was listed. Where oils were added to foods, the main oil and percentage contribution to the product was collated. The range of products available was also analysed by product type and age category for which it was marketed. Products were identified using three different supermarket websites and one pharmaceutical website. The search terms ‘infant’ and ‘toddler’, combined with ‘snacks/snack foods’ were used to identify the products. Infant formulas, fortified milk, beverages and ready meals were excluded from the analysis. Data was categorised into the following groups:

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PAEDIATRIC SUPPLEMENT Table 1: Macronutrient profile of infant/toddler snack foods (per 100g) Product

Energy (kcal)

Protein (g)

CHO (g)

Sugars (g)

Fat (g)

Saturated fat (g)

Fibre (g)

Salt (g)

Biscuits

429.6

9.3

68.8

16.5

12.8

4.1

4.9

0.4

Bars

386.7

6.3

97.2

31.7

11.9

2.1

6.4

0.1

Crisps/puffs

453.4

6.8

65.4

6.3

18.1

2.6

3.5

0.5

Crackers/ bread sticks

444.6

11.9

65.7

2.5

14.3

4.9

3.4

0.6

Rice cakes

388.2

7.3

85.1

12.0

1.6

0.4

1.9

0.1

Fruit-based snacks

317.3

2.6

69.2

54.9

2.2

1.0

7.5

0.1

Vegetablebased snacks

431.3

7.6

69.8

16.1

12.4

1.2

6.2

0.5

1 Biscuits 2 Bars 3 Crisps/puffs 4 Crackers 5 Rice cakes 6 Fruit-based snacks 7 Vegetable-based snacks Nutrients listed on the food labels were also collated. RESULTS

A total of 98 snack products were identified. Of these, one-quarter were fruit-based snacks (dried fruit pieces/gummies), 22% were biscuits, 17% rice cakes, 15% crisps or puffs, 13% were bars, 6% vegetable-based snacks and 5% crackers or breadsticks. The mean macronutrient profile of infant/ toddler snacks is presented in Table 1. Fruitbased snacks had the lowest energy, protein, fat and saturated fat content. They also had the highest fibre content (along with snack bars). Pairwise comparisons showed that fruit-based snacks and bars contained significantly more fibre content than options such as rice cakes (P<0.05). The total sugar content of fruit-based products was, however, the highest at 54.9g. Crackers/bread sticks had the highest protein content and provided most salt. Crisps and puffs typically had the highest total fat content. Pairwise analysis found levels of saturated fat were significantly higher in biscuit, crisps/puffs and crackers/breadstick products compared with rice cake products (P<0.05). 16

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Vegetable-based snacks were surprisingly high in energy and total fat, possibly due to oils added. Sunflower oil was used in the majority of products (62%), although over one-third (36%) used palm oil (Figure 1). An analysis of nutrients listed on food labels revealed that thiamine was the most commonly reported nutrient (listed on 48.5% of products), possibly due to flour fortification. After this, less than 10% of products reported listing key nutrients such as iron, vitamin D, zinc or calcium, indicating that the nutritional density of infant/ toddler products appears to be low (Figure 2). DISCUSSION

It is important that the right food choices are available for infants and toddlers, which help to satisfy appetite whilst providing a good source of nourishment. It is well established that earlylife experiences with healthy tastes and flavours can go a long way towards promoting healthy eating. This, in turn, can play a significant role in addressing the many chronic illnesses associated with poor food choices.7 Whilst fruit-based snacks low in fat are a great provider of fibre, they also contain a high amount of fruit sugars. Given this, it would be good to see a greater range of savoury and vegetable-based products, preferably with a lower fat content and using fewer oils such as palm oil.8 It is important that a range of products are eaten to disperse intakes of fat, protein and fibre. Equally, snacks, such as fresh vegetables and fruits, should not be overlooked.

Figure 1: Types of oils used in infant/toddler foods

Figure 2: Micronutrients listed on food labels (% of products)

Whist it is good to see that most products are now moving away from using ‘added sugars’, this does not necessarily mean that they are moving away from sources of ‘sweetness’ per se, with alternatives creeping in. With regard to salt content, this was highest in crackers and breadstick-type products, though most products are well balanced in this sense. The micronutrient profile of commercial infant/ toddler snack products was somewhat disappointing, indicating that current snack products appear to be more about providing fuel and different flavours. There is certainly scope to evaluate the vitamin D content of infant and toddler foods given deficiency concerns and poor compliance with supplements during the early years.

CONCLUDING REMARKS

Taken together, whilst the infant and toddler snack product market is evolving, there is still much work to be done. Improvements are being made in terms of not using added sugars and monitoring of salt levels. However, when looking at the ‘variety’ of foods available, sweet tasting products continue to dominate in favour of more savoury and alternative tastes. Whilst current snack products appear to provide a basic source of fuel, they do not seem to be provide much more beyond this. Fruitbased snacks do appear to be an important provider of fibre, but the general micronutrient profile of current infant/toddler commercial snack foods seems to be lagging behind. www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT

NUTRITION IN SCHOOLS Maeve Hanan Registered Dietitian, City Hospitals Sunderland, NHS

Creating a healthy school environment which encourages nutritious food choices has numerous benefits for children; it can support general health and growth, improve dental health, reduce the risk of gaining excess weight, foster longer-term healthy habits, improve energy and mood levels and also optimise learning.

Schools have opportune contact with families and the ability to signpost them to healthy lifestyle information. Schools can also help to reduce the gap of food poverty and health inequality by providing access to healthy food during the school day and by running initiatives such as breakfast clubs; which have been associated with improved educational attainment, better school attendance and improved general health.1

For full article references please email info@ networkhealth group.co.uk

SCHOOL FOOD STANDARDS

In the UK, school meals are free for children from reception to Year 2 and also for those who receive certain income support or tax credits as outlined in the Education Act 1996.2 In England, the government-run ‘School Fruit and Vegetable Scheme’ provides four- to six- year-old pupils in state-funded schools with a free daily piece of fruit or vegetable outside of lunchtime, although it is not mandatory for schools to participate in this scheme.3 Some pupils are also eligible to receive up to 250ml of free or subsidised milk products each school day via the school milk subsidy scheme.4 English local authority schools, academies which opened before 2010 and certain free schools must adhere to the ‘School Food Standards’ outlined in the updated ‘School Food Plan’ which was implemented in England in 2015, and all remaining schools can sign up to these standards voluntarily.3,5 These Standards aim to improve the nutrition

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and dietary habits of school-aged children with an emphasis on creating a positive environment for meals and educating children about sustainable healthy choices and the importance of a varied and balanced diet. Ofsted supports the School Foods Standards and there are also award schemes to encourage active participation, such as ‘The Children’s Food Trust Excellence Award’ and ‘The Food for Life Partnership’.5 The School Food Standards work alongside the ‘Government Buying Standards for Food and Catering Services’ and applies to all food provided in schools up to 6pm, including: breakfast clubs, snacks at mid-morning break, school lunches, after school clubs, vending machines and tuck-shops.5 However, they do not apply to: parties, fundraising events, cookery sessions, or celebrations of religious/cultural occasions.4 These standards also provide specific guidance on appropriate portion sizes for different age groups, how to manage food allergies and intolerances and signposting to resources, such as: example menus, recipes, checklists, information on interpreting food labels and cooking tips for school caterers.5 Specifically, the School Food Plan recommend:3,5 • plenty of fruit, vegetables and unrefined starchy foods; • some meat, fish, eggs, beans, milk and dairy (and dairy-free alternatives) daily;

Figure 1: Standards for school lunches5

The standards for school lunches

Starchy foods

Fruit and Vegetables

Milk and dairy

One or more portions of food from this group every day

One or more portions of vegetables or salad as an accompaniment every day

A portion of food from this group every day

Three or more different starchy foods each week

One or more portions of fruit every day

One or more wholegrain varieties of starchy food each week

A dessert containing at least 50% fruit two or more times each week

Lower fat milk must be available for drinking at least once a day during school hours

Starchy food cooked in fat or oil no more than two days each week (applies across the whole school day)

At least three different fruits and three different vegetables each week

Bread - with no added fat or oil - must be available every day

Healthier drinks

Foods high in fat, sugar and salt Meat, fish, eggs, beans and other non-dairy sources of protein

A portion of food from this group every day A portion of meat or poultry on three or more days each week Oily fish once or more every three weeks For vegetarians, a portion of non-dairy protein on three or more days each week A meat or poultry product (manufactured or homemade, and meeting the legal requirements) no more than once each week in primary schools and twice each week in secondary schools (applies across the whole school day)

No more than two portions of food that have been deep-fried, batter-coated, or breadcrumb-coated, each week (applies across the whole school day) No more than two portions of food which include pastry each week (applies across the whole school day) No snacks, except nuts, seeds, vegetables and fruit with no added salt, sugar or fat (applies across the whole school day)

applies across the whole school day Free, fresh drinking water at all times The only drinks permitted are: •

Plain water (still or carbonated)

•

Lower fat milk or lactose reduced milk

•

Fruit or vegetable juice (max 150mls)

•

Plain soya, rice or oat drinks enriched with calcium; plain fermented milk (e.g. yoghurt) drinks

•

Combinations of fruit or vegetable juice with plain water (still or carbonated, with no added sugars or honey)

•

Combinations of fruit juice and lower fat milk or plain yoghurt, plain soya, rice or oat drinks enriched with calcium; cocoa and lower fat milk; flavoured lower fat milk, all with less than 5% added sugars or honey

•

Tea, coffee, hot chocolate

Savoury crackers or breadsticks can be served at lunch with fruit or vegetables or dairy food No confectionery, chocolate or chocolatecoated products (applies across the whole school day) Desserts, cakes and biscuits are allowed at lunchtime. They must not contain any confectionery Salt must not be available to add to food after it has been cooked (applies across the whole school day) Any condiments must be limited to sachets or portions of no more than 10 grams or one teaspoonful (applies across the whole school day)

Combination drinks are limited to a portion size of 330mls. They may contain added vitamins or minerals, and no more than 150mls of fruit or vegetable juice. Fruit or vegetable juice combination drinks must be at least 45% fruit or vegetable juice

• limiting foods and drinks high in fat, sugar and salt; • increasing the iron, zinc and calcium content of school menus; • free drinking water to be available at all times; • hot lunches to be available when possible to encourage at least one hot meal per day for pupils; • facilities to be available for those who bring in packed lunches;

• detailed guidance for school lunch standards as outlined in Figure 1. TACKLING CHILDHOOD OBESITY IN SCHOOLS

Obesity is an increasingly important issue to be aware of in a school setting. Figures from 2014 to 2015 in England reported that more than a fifth of children in reception were overweight or obese (22.6% for boys, 21.2% for girls), and roughly a third of children in year six www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Table 1: Childhood obesity health risk Endocrine problems

Type 2 diabetes, impaired glucose tolerance, premature puberty

Respiratory disorders

Asthma, obstructive sleep apnoea, reduced exercise tolerance

Cardiovascular disorders

Hypertension, hyperlipidaemia

Musculoskeletal problems

Blount’s disease, back/knee/hip/ankle/foot pain

Psychological problems

Low self-esteem, stress and anxiety, poor social skills, behavioural problems, increased risk of eating disorders

Gastrointestinal disorders

Non-alcoholic steatohepatitis (NASH)

Increased risk of chronic diseases in adulthood

Heart disease, stroke, dementia, certain cancers (e.g. breast, colon, endometrial), liver disease

Other issues

Fatigue, skin infections due to moisture in skin folds, the potential to affect lifetime attainment, possible reduced longevity

were overweight or obese (34.9% boys, 31.5% girls).6 This is worrying as childhood obesity is related to numerous health risks as outlined in Table 1.7-8 In order to tackle the issue of increasing childhood obesity levels, in 2016 the World Health Organisation (WHO) released its Report of the Commission on Ending Childhood Obesity which highlights ‘health, nutrition and physical activity for school aged children’ as one of its core areas for improvement.9 Specific recommendations within this report include: • promoting healthy school environments; • health and nutrition literacy as a core part of the curriculum; • physical activity in schools including good quality PE; • developing healthy standards for food and drink provided in schools; • cookery classes for pupil and their parents or guardians; • regularly monitoring children’s growth at school or with the family’s GP to identify those who need extra support or input; • banning the marketing of unhealthy food and drinks in areas where children and adolescents gather including schools, in line with Resolution 63.14 from the World Health Assembly10 as school aged children, and particularly adolescents, are vulnerable to marketing strategies of unhealthy options. 20

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In response to this, the UK government also released its ‘Childhood Obesity: A Plan for Action’ in 2016.1 Working with schools is described as a vital part of this plan with four of the 14 main areas targeted to for improvement being directly linked to health promotion within school: 1. Encouraging an hour of physical activity per day for all children Research shows that physical activity levels start to reduce from the age that children start school, which is worrying, as physical activity has numerous benefits such as improved fitness, healthier bones and joints, mood, sleep quality and academic performance.1,10 Therefore, all primary school children should receive at least 30 minutes of physical activity within school time via activity at break times, extra-curricular clubs, PE, active classes or other physical activity opportunities; and the remaining 30 minutes should occur outside of school. The proceeds from the soft drinks industry levy is to provide extra funding for promoting physical activity in schools. This will be taken into account during Ofsted inspections and the new healthy schools rating scheme. Public Health England will be devising further advice for the academic year of 2017-2018 about how schools can utilise all relevant resources to create a healthier lifestyle for its pupils.

Schools clearly play an important role in influencing the nutrition, health and wellbeing of children.

2. Improving sport and physical activity programmes in schools From September 2017, all primary schools in England should have access to good quality local and national sport and physical activity programmes which may include strategies to promote walking and cycling to school. These programmes will be co-ordinated by county sports partnerships, national governing bodies of sport, the Youth Sport Trust and other relevant providers. 3. Creating a healthy rating scheme for primary schools A voluntary Ofsted recognised scheme for UK primary schools will be introduced in September 2017 to encourage healthier eating and more physical activity, which will include an annual competition to celebrate schools with the best projects for promoting health and tackling obesity. In 2017 Ofsted also plans to produce a best practice report to provide guidance for schools on healthy eating, physical activity and reducing obesity levels.

4. Making school food healthier The Department for Education in the UK plans to update the current School Food Standards to include the most recent evidence-based guidelines on nutrition (for example, the updated recommendations on carbohydrates and sugar). The Secretary of State for Education will also run a campaign to encourage all schools to adhere commit to the School Food Standards, as some academies and free schools are not currently required to follow this scheme.3 Also, 10 million pounds per year from the soft drinks levy has been proposed to set up more healthy breakfast clubs in the UK. CONCLUSION

Schools clearly play an important role in influencing the nutrition, health and wellbeing of children. Hopefully the recent emphasis on this in school specific guidelines, which aim to tackle the global health issue of childhood obesity, will result in improved compliance with school food standards in order to optimise the health of all pupils and set them up for lifelong healthy habits. www.NHDmag.com May 2017 - Issue 124 - Supplement

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