7.0 Clinical nutrition - Queensland Health

1A HEALTHY START IN LIFE CLINICALNUTRITION

7.0 Clinical nutrition7.1 Adverse food reactions Foodallergiesandintolerancesareexamplesofadversefoodreactionsanddescribeadversereactionstofoods.Regardlessofwhetherclassifiedaseitheranallergyorintolerance,dietarymanagementshouldbehandledbyaqualifieddietitian/nutritionist(inconjunctionwithanallergistinthecaseoffoodallergies),sinceselfimposedrestrictionsmayleadtonutritionaldeficiencies.Theareaoffoodallergiesandintolerancesisnotatallclear-cut.Accuratediagnosisisessential,andthisusuallyrequiresareferralfromaGeneralPractitionertoanAllergist.

Understanding food allergies and intolerancesThissectioniskindlyadaptedfromFriendly Food,RoyalPrinceAlfredHospitalAllergyUnit.

Understandingthedifferencebetweenintoleranceandothertypesoffoodreactionisanimportantstartingpointbecausetheapproachtodealingwiththemisquitedifferent.Unlikeallergiesandcoeliacdisease,whichareimmunereactionstofoodproteins,intolerancesdon’tinvolvetheimmunesystematall.Theyaretriggeredbyfoodchemicalswhichcausereactionsbyirritatingnerveendingsindifferentpartsofthebody,ratherinthewaythatcertaindrugscancauseside-effectsinsensitivepeople(2).

Thechemicalsinvolvedinfoodintolerancesarefoundinmanydifferentfoods,sotheapproachinvolvesidentifyingthemandreducingyourintakeofgroups of foods,allofwhichcontainthesameoffendingsubstances.Bycontrastproteinallergensareuniquetoeachfood(forexample,egg,milkandpeanut),anddealingwithafoodallergyinvolvesidentifyingandavoidingalltracesofthat particular food. Similarlygluten,theproteininvolvedincoeliacdisease,isonlyfoundincertaingrains(wheat,barley,rye)andtheireliminationisthebasisofagluten-freediet(2).

If food allergy is suspected, refer patient to an allergist or immunologist for assessment.

Understanding food allergiesAfoodallergyisanabnormalimmunereactiontoafoodthatisharmlessformostpeople.Antibodiesagainstthefoodareproducedsothatwhentheallergicindividualeatsthefood,histamineandotherdefensivechemicalsarereleasedcausinginflammation.Thesechemicalstriggerallergicsymptomsthatcanaffecttherespiratorysystem,gastrointestinaltract,skinorcardiovascularsystem(5).

Arathershortlistoffoodsaccountsfor85-90%ofsignificantreactions,althoughanyfoodcanprovokeareaction.Foodsresponsibleforthemajorityofsignificantfoodallergyininfants,childrenandadultsareasfollows:

infants:cow’smilk,soy■■

children:cow’smilk,egg,peanut,soy,wheat,treenuts(walnuts,hazelnutsetc),fish,■■

shellfish

adults:peanut,treenuts,fish,shellfish(9)■■

Fortunately,mostchildrengrowoutoftheireggandmilkallergiesbeforetheyreachschoolage,orduringtheearlyschoolyears,butallergiestonutsandseafoodscanpersist.Wheatandsoycancauseallergies,buttheytendtobemildandtransient(2).

2 A HEALTHY START IN LIFE CLINICALNUTRITION

Common food allergens (2, 3, 5)

Peanutandothernuts■■

Egg■■

Milk■■

Seafood■■

Sesame■■

Wheat■■

Soy■■

Children born into atopic families are more likely to develop allergic diseases (50-80% risk) compared to those with no family history of atopy (20% risk) The risk appears to be higher if both parents are allergic.. and if the mother (rather than the father) has allergic disease (8)

Symptoms usually begin in the first 2 years of life, often after the first known exposure to the food… It is estimated that up to 6% of children under 3 years of age are affected by food allergies (3).

Formoreinformation,thehandoutsbelowcanbeaccessedattheRoyalPrinceAlfredHospitalwebsite:www.cs.nsw.gov.au/rpa/Allergy/default.htm

Egg Allergy■■

Frequently Asked Questions about Food Allergies (includes Advice for Schools)■■

Latex Allergy■■

Milk Allergy■■

Peanut Allergy■■

Food Allergy Prevention■■

Upper Airway■■

Wheat Allergy■■

Food allergy reactions (2)

Foodallergyreactionsvaryinseverity,dependingonhowsensitivethepersonisandhowmuchofthefoodthey’veeaten.

Foodallergyismainlyaproblemofinfants,toddlersandyoungchildren.Over90%ofcasesareassociatedwithatopiceczema-anintenselyitchychronicskinrashaffectingtheface,arms,legs,andotherpartsofthebody(2).

Moreseverereactionsareusuallyobviousandoccurconsistently,everytimethepersonhasthefood.Contactwiththemouthandtonguecancauseanimmediateburningsensation,withhivesandrednessaroundthefaceandifthefoodisswallowed,animmediatefeelingofbeingunwellcanbefollowedbyvomiting,crampsanddiarrhoea.Theface,mouthandeyescanswelldramatically,andhivesonthebodycanjoinintolarge,rapidlyspreadingwelts(2).

Themostseveretypeofreaction–anaphylaxis-canprogressrapidlywithbreathingdifficulty(fromswellingofthethroatorsevereasthma),allergicshockandcollapse,andcanbelife-threateningifnottreatedimmediatelywithadrenaline(epinephrine)byinjection.Inthemostsensitivepeoplewithafoodallergy,tinyamountsofthefood(pin-headsized)canbeenoughtoprovokeaseverereaction(2).


Minimising the risk of allergy in high-risk infants (1, 8)

Pregnancy

Do not smoke during pregnancy, and provide a smoke-free environment for your child after ■■

birth.

Dietary restrictions in pregnancy are not recommended.■■

Breastfeeding, formula feeding

Exclusively breastfeed your child for at least 6 months, and preferably longer.■■

If breastfeeding is discontinued for any reason, seek professional advice: hydrolysed ■■

protein formula may be recommended.

Soy milk and goat’s milk formulas do not reduce allergies, and should not be used as an ■■

alternative to cow’s milk formulas.

Maternal dietary restrictions during breastfeeding are not recommended for prevention (8)■■

If an infant is breastfeeding and showing signs of allergies, refer to local general ■■

practitioner or specialist (eg paediatrician, allergist).

Introducing solids

Solid foods should not be introduced until about 6 months of age.■■

Start with low-allergenic foods such as rice and rice based cereals, followed by vegetables ■■

(eg. potato, pumpkin) and fruits (pear, apple, banana), then meats.

Add only one food at a time. Wait several days (ideally 5 to 10 days) before introducing a ■■

new food.


ManagementDietary Guidelines for Children and Adolescents in Australia recommendation

Encourageexclusivebreastfeedingfor6monthstodecreasetheriskofallergyininfantswithapositivefamilyhistory.

Ifthereisastrongfamilyhistoryofallergy,delayintroducingsomeorallofthehighlyallergenicfoodsduringthefirstyear;amongthesefoodsarecow’smilkandotherdairyproducts,soy,eggs,nuts,peanutsandfish.

Itisbesttocontinueavoidingeggs,nutsandshellfishuntiltheageof3years.

Whenfoodchoicesarerestricted,theadviceofadietitianshouldbesoughttoensurethatthedietaryintakecontinuestomeetnutrientandenergyneeds.

BestPracticemanagementisessential;refertopaediatricianoranallergist.

Dietary interventionThemainprincipleoffoodallergymanagementisavoidanceoftheoffendingantigen.Anincorrectdiagnosisislikelytoresultinunnecessarydietaryrestrictions,which,ifprolonged,mayadverselyaffectthechild’snutritionalstatusandgrowth.Forpatientsrequiringprolongedrestrictivediets,aformaldieteticevaluationisrecommendedtoensurethatnutritionalrequirementsaremet(3).

Food Intolerances

Foodintolerancesareanadversereactiontoafoodorsubstancethatdoesnotinvolvetheimmunesystem(5).Foodintolerancereactionscanbetriggeredbyarangeofnaturalsubstancesoradditivespresentinmanydifferentfoods.

Somepeoplearebornwithasensitiveconstitutionandreactmorereadilytofoodchemicalsthanothers.Thetendencyisprobablyinherited,butenvironmentaltriggerscanbringonsymptomsatanyagebyalteringthewaythebodyreactstofoodchemicals.Thesetriggersmayinclude:

asuddenchangeofdiet■■

abadfoodordrugreaction■■

anastyviralinfection;forexample,gastroenteritisorglandularfever(2).■■

Natural food chemicals

Naturalchemicalsarefoundinthefoodsweeat.Foodiscomposedofprotein,carbohydrate,fatandvariousnutrientsaswellasanumberofnatural‘chemicals’.Thesenaturallyoccurringmoleculesoftenaddflavourandsmelltofood.Sometimestheywilltriggersymptomsinunluckyindividuals.Thesechemicalsinclude(6):

salicylates■■

amines■■

glutamate.■■

Thesenaturalsubstancesaretheonescommontomanydifferentfoods,andthereforeconsumedingreatestquantityinthedailydiet.Asarule,thetastierafoodis,thericherit’slikelytobeinnaturalchemicals.

It is important to realise that reactions to these substances are not due to allergy, and so allergy testing is of little use in helping us to decide what to avoid (6).


Chemical threshold Thesmallamountsofnaturalchemicalspresentinaparticularfoodmaynotbeenoughtocauseareactionstraightaway.However,becauseonesubstancemaybecommontomanydifferentfoodsitcanaccumulateinthebody,causingareactionwhenthethresholdisfinallyexceeded(2).

Food intolerance reactions (2)Symptomstriggeredbyfoodchemicalintolerancesvaryfrompersontoperson.Commononesinclude:

recurrenthivesandswellings■■

headaches■■

sinustrouble■■

mouthulcers■■

nausea■■

stomachpains■■

bowelirritation.■■

Somepeoplefeelvaguelyunwell,withflu-likeachesandpains,orgetunusuallytired,run-downormoody,oftenfornoapparentreason.

Management of food intolerances Thechemicalsinvolvedinfoodintolerancesarefoundinmanydifferentfoods,sotheapproachinvolvesidentifyingthemandreducingtheintakeof groups of foods,allofwhichcontainthesameoffendingsubstances(2).

Elimination dietsOnceadiagnosisismade,thehistorymayhelpidentifytheroleofdietaryorotherfactorsinmakingsymptomsworse.Theonlyreliablewaytosortoutwhetherdietisplayingaroleisbypeoplebeingplacedonatemporaryeliminationdietunder the supervision of a skilled dietitian and medical practitioner.Ifthediethelps,thisisfollowedbychallengesundercontrolledconditionstoidentifydietarytriggerssothattheycanbeavoidedinthefuture(6).

Itisimportanttoemphasiseeliminationdietsmustonlybeundertakenforashortterm,understrictmedicalsupervisionandonlyforverygoodreasons.Prolongedrestricteddietscanleadtoproblemswithnutrition,particularlyinchildren(6).

Refertoadietitian.

Parenthandoutcanbefoundat

www.medeserv.com.au/ascia/aer/infobulletins/food_intolerence.htm


Coeliac diseaseThissectioniskindlyadaptedfromFriendly Food,RoyalPrinceAlfredHospitalAllergyUnit.

Coeliacdiseaseiscausedbyanimmunereactiontogluten,aproteinfoundinwheat,barleyandrye.Thereactioncausesinflammationanddamagetotheliningofthesmallbowel,whichimpairsitsabilitytoabsorbnutrients.Typicalsymptomsincludemouthulcers,fatigue,bloating,crampsanddiarrhoea,butsomepeoplehavenosymptomsatall,andinotherstheonlycluemaybeanaemia(duetoironorfolicaciddeficiency)oranunusualchronicskinrash(dermatitis

herpetiformis). Coeliacdiseaseshouldnotbeconfusedwithwheatallergy,whichrarelyoccursbeyondinfancy,orthestomachandbowelirritationthatglutencansometimescauseinpeoplewithchemicalintolerances.

Screeningbloodtestsareavailable,butdefinitediagnosisrequiresasmallbowelbiopsy.Thesetestscanbecomenegativeafterafewweeksofglutenavoidance.Untreatedcoeliacdiseasecarriesalong-termriskofnutritionaldeficiency,osteoporosisand/orbowelmalignancy.Currently,alife-longgluten-freedietistheonlyknowntreatment.

Useful websites and resourcesDietary Guidelines for Children and Adolescents in Australia

Clinical guidelines

KatrinaJAllen,DavidJHill,RalfGHeine.FoodAllergyinChildhood.MJA185(7)394-400.

www.mjw.public/issues/182_09_020505/pre10874_fm.html

SusanLPrescottandMimiLKTang(2005).TheAustralasianSocietyofClinicalImmunologyandAllergypositionstatement:summaryofallergypreventioninchildrenMJA182(9)464-467.www.mja.com.au/public/issues/185_07_021006/all10609_fm.pdf

Parent books, DVDs

Friendly Food(MurdochBooks)byAnneSwain,VelenciaSoutterandRobertLoblay,RoyalPrinceAlfredHospitalAllergyUnit.

Orderformcanbefoundatwww.cs.nsw.gov.au/rpa/Allergy/default.htm

“DealingwithFoodAllergy”DVDandbooklet–availablefromRoyalPrinceAlfredHospital.

Parenthandoutsregardingfoodallergyandintolerancecanbefoundat www.foodauthority.nsw.gov.au/consumer/c-allergies.htmlincludingtranslatedinformationsheetsineightdifferentlanguages.


A note on the Australasian Society of Clinical Immunology and Allergy (ASCIA)

ASCIAisaprofessionalnonprofitorganisation,comprisedpredominantlyofClinicalImmunologists,AllergySpecialistsandImmunologyScientists.ThemainrolesofASCIAareto:promotethehigheststandardsofscientificandmedicalpracticeandeducationamongstitsmembers…..andtocoordinateeducationprogrammesforitsmembers,otherhealthprofessionalsandthepublic.

Contact information:

ExecutiveOfficerTheAustralasianSocietyofClinicalImmunologyandAllergy(ASCIA)POBox450BalgowlahNSW2093

Email: [email protected]

Website: www.allergy.org.au

Patienteducationresourcescanbefoundatwww.allergy.org.au/aer/infobulletins/index.htm

A note on the Royal Prince Alfred Hospital (RPAH)

TheRPAHAllergyUnitisattachedtotheDepartmentofClinicalImmunology,RoyalPrinceAlfredHospital(RPAH),andisaffiliatedwiththeDisciplineofMedicineattheUniversityofSydney.ThestaffattheAllergyUnitarecommittedtoexcellenceinclinicalcare,researchandteaching,andactasacentreofnationalexpertiseprovidinginformationandresourcematerialsforhealthcareprovidersaswellasthewidercommunity.

Contact information:

Email: [email protected]

Website: www.cs.nsw.gov.au/rpa/Allergy/default.htm


ReferencesDietaryGuidelinesforChildrenandAdolescentsinAustraliaincorporatingtheInfant1.FeedingGuidelinesforHealthWorkers,NHMRC,Canberra2003.

FriendlyFood(MurdochBooks)byAnneSwain,VelenciaSoutterandRobertLoblay,2.RoyalPrinceAlfredHospitalAllergyUnit.

AllenKJ.,HillDJ.,HeineRG.,(2006)FoodAllergyinChildhood.MJAPracticeEssentials3.185(7)394-400

FoodAllergyPrevention;RPA4.www.cs.nsw.gov.au/rpa/Allergy/default.htm[online]5thApril,2007

NSWFoodAuthority:FoodAllergiesandsIntolerancesFactSheet:25thAugust2005.5.[online4thApril]www.foodauthority.nsw.gov.au

www.medeserv.com.au/ascia/aer/infobulletins/food_intolerence.htm6. [online10thApril]

BischoffS.,CroweS.E.,(2005)GastrointestinalFoodAllergy:NewInsightsInto7.PathophysiologyandClinicalPerspectives.Gastroenterology2005;128:1089-1113

SusanLPrescottandMimiLKTang(2005)TheAustralasianSocietyofClinical8.ImmunologyandAllergypositionstatement:summaryofallergypreventioninchildrenMJA182(9)464-467

AmericanGastroenterologicalAssociationmedicalpositionstatement:guidelinesforthe9.evaluationoffoodallergies,Gastroenterology2001Mar;120(4)1023-5

PrescottS.L.,TangM.,(2004)TheAustralasianSocietyofClinicalImmunologyandAllergy10.positionstatement:Allergypreventioninchildren.[online]10thAprilwww.allergy.org.au/pospapers/Allergy_prevention.htm


7.2 ColicTheword‘colicky’isusedtodescribeafussybabywhoisotherwiseahealthy,growinginfantyoungerthan4months.Whethercolicexistsasaseparateentityorasasymptomofamaternalproblemisoftendebated.

InarecentAustralianstudy60%ofparentsreportedthattheirbabieshadsufferedfromcolic.Eventhoughcoliciscommoniscanbeverydistressingfortheparentsandotherfamilymembers.Inconsolable,unexplainedandincessantcryinginaseeminglyhealthyinfantgivesrisetotired,frustratedandconcernedparents(1).

Normal patterns of crying

Allinfants,whetherornottheyhavecolic,crymoreduringthefirst3monthsoflifethanatanyothertime.Onestudydescribescryingpatterns–cryinglastedapproximately2hoursperdayat2weeksofage,increasedtoapeakof3hoursadayat6weeks,andgraduallydecreasedtoabout1hourby3monthsofage.Thehypothesesforthesefindingswerethattheaccumulatedexcitementcausedbyenvironmentalstimuliduringthedaywasdischargedintheformofcryingduringlateafternoonandevening(2).

Mostofthefeaturesofcryingininfantswithcolicalsooccurinnormalinfantsbutwithlessfrequencyandshorterduration.

AcommonlyusedcriterionfordefiningcolicistheWessel’sruleofthrees,whichstatesthatinfantilecolicinvolvescryinglastingforatleast3hoursaday,foratleast3daysinanyweek,foratleast3weeksinthefirst3or4monthsoflife.

Therehavebeenmanyarticlesandresearchreportspublished,yetstilllittleisknownaboutthecauseorwhattodoaboutit.Somestudiessuggestcoliccanbecausedbyfoodallergies,gastrointestinalproblems,environmentalandbehaviouralfactors.Otherssuggestthatitisnormalforinfantstofussandhaveincreasinglylongerboutsofcryingfrombirthtoabout6weeks,afterwhichthecryingdecreases.

Recommendations from the Dietary Guidelines for Children and Adolescents in Australia

Changesindietsandrestrictionsonindividualfoodshavehadaverylimitedsuccessinthetreatmentofcolic.Ensuredietarymodificationorpharmacologicalinterventionissafeanddoesnotresultinnutritionaldeficiencies.

Tips for practice

Providereassurancethattheinfantishealthy.■■

Athoroughexaminationandhistoryshouldbeconducedtoeliminateotherpossible■■

physiologicalproblems.

Establishiftheinfantiscryingforotherreasonssuchashunger,temperature,boredom.■■

Establishtheinfant’sdiet,indicationsofreflux,sleepingpatterns,bowelandurination■■

patterns.

Askaboutthegeneralwellbeingoftheparentsandthesocialsituationoftheinfant.■■


Resourceswww.raisingchildren.net.au/articles/colic:_what_to_do.html/context/255

www.raisingchildren.net.au/articles/colic:_what_is_it.html

www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=304&id=1735

www.gut.nsw.edu.au/pcinfo1.htm

www.gut.nsw.edu.au/free1.htm

www.healthinsite.gov.au/

www.healthinsite.gov.au/topics/Colic

ReferencesJBI2004,TheEffectivenessofInterventionsforInfantColic,1. Best Practice8(2)1-6.www.joannabriggs.edu.au/pdf/BPIScolic.pdf

TurnerT.L.,(2006)Clinicalfeaturesandaetiologyofcolic:[online]18thApril2007,2.www.uptodateonline.com/utd/content/topic.do?topicKey=behaviour/2155


Intentionally blank


Intentionally blank


7.3 Constipation – keeping things moving!Recommendations from the Dietary Guidelines for Children and Adolescents in Australia

To avoid unnecessary intervention, parents need to be educated about the wide variation in normal bowel function in infants (particularly those who are breastfed) and toddlers.

Therehavebeensomerecentchangesinthewayconstipationisbeingmanaged.Thissectionwillgiveyouanoverviewofmanagementplans,andprovidesomedetailedadviceonwhenreferralsarenecessary.

Anormalpatternofstoolevacuationisthoughttobeasignofhealthinchildrenofallages.Especiallyduringthefirstmonthsoflife,parentspaycloseattentiontothefrequencyandthecharacteristicsoftheirchildren’sdefecation.Anydeviationfromwhatisthoughtbyanyfamilymembertobenormalforchildrenmaytriggeracalltothenurseoravisittothepaediatrician(4).

Stoolconsistencyandfrequencycanbeveryvariableininfantsandchildren.Healthybreastorformulafedinfantsmaypassstoolsasregularlyasaftereveryfeedorasseldomasonceaweek.Aslongasthestoolsaresoftandeasilypassedandtheinfantiscontinuingtogrowappropriately,thereisgenerallynocauseforconcern.Somefoodswillchangestoolstoadifferentcolour,forexample,spinachmaycausedarkgreenstoolsorbeetrootmaycauseareddishcolour.

Chronic constipation is a source of anxiety for parents who worry that a serious disease may be causing the symptoms (4).

Constipationinchildhoodiscommon,withareportedprevalencerangingfrom0.3–28%.Faecalsoilingoccursin1–3%ofchildrenaged4–7years(2).

Symptoms persist beyond puberty in about 30% of children with constipation and soiling (2)

DefinitionAninfantorchildisconsideredconstipatedifthereispainassociatedwithpassingstoolsandthestoolsarehardordry.Infrequencyisinsufficientgroundsuponwhichtomakeadiagnosisofconstipation.However,thereisgeneralacceptancethatitisabnormaltohave

stoolfrequencyoflessthan3timesperweek,■■

hardpainfuldefecation■■

periodicpassageofverylargeamountsofstoolatleastonceevery7–30days■■

orapalpableabdominalorrectalmassonphysicalexamination(2).■■


Normal bowel functionWhatisstrikingisthevarianceofnormalfrequencyofbowelmovements,particularlyininfants;breastfedbabies0–3monthsold,rangefrom5–40bowelmovementsperweek(4).

Normal bowel function (1, 2, 3)

Firstbowelactionconsistsofmeconium,whichisgreenish-black■■

24–48hoursmeconiumchanges;browntransitionalstools■■

Breastfed:■■

3■■ rdor4thday,mustardcoloured

Mayalsobegreenororange■■

Milkcurdsmaybepresent■■

6weeksto3months-numberofbowelmotionsdecrease;intervalsofseveraldaysor■■

morearecommon

Babiesolderthan2monthsmaynormallyhaveinfrequentstools,sometimesupto■■

1–2weeksapart(1)

Formulafedbabiespassfewerstools,onceadayoreverysecondday,khakicoloured■■

andplasticinelikeconsistency

Meconiumispassedwithinthefirst24hoursinabout87%ofinfantsandwithin48hoursby99%;thisisnotinfluencedbywhethertheinfantisreceivingbreastmilkorformula(2).

Subsequently,however,themethodoffeedinghasasignificantimpactonstoolfrequency,colourandconsistency.Breast-fedinfantspasssofter,uniformlyyellowstoolsupto5timesaday.Thisismorefrequentthaninbottle-fedinfants.However,breast-fedinfantsmayoccasionallyhavenobowelactionsfor3daysormore,whichisrareinbottle-fedinfants.Withinthefirstfewweeksoflife,64%ofbreast-fed,butonly30%ofbottle-fed,infantsarehavingmorethan3bowelactionsaday(2).

Stoolfrequencyreducesprogressivelywithage,sothatby16weeksofagebothbreastfedandbottlefedinfantsarepassingonaverage2stoolsaday.

Hard, dry motions are more likely to occur after formula or solids are introduced (1).

Pleasenote:continuedpassageofmeconiuminthefirstcoupleofmonthsmaybeasignofinadequatemilkintakeandmaybethefirstsignofanunderfedbaby(1).SeeFailuretoThrivesection.


Aetiology of constipationThe aetiology of constipation and soiling is multifactorial.

Functional constipation (2,4)

Constipationwithoutobjectiveevidenceofapathologicalcondition.Itismostcommonlycausedbypainfulbowelmovementswithresultantvoluntarywithholdingoffaecesbyachildwhowantstoavoidunpleasantdefecation(seeBox2).Withholdingfaecescanleadtoprolongedfaecalstasisinthecolon,withreabsorptionoffluidsandanincreaseinsizeandconsistencyofthestools.

Up to 63% of children with constipation and faecal soiling will have a history of painful defecation beginning before 3 years of age and secondary withholding behaviour (2).

Events leading to painful defecation (4)

toilettraining■■

changesinroutineordiet■■

stressfulevents■■

intercurrentillness■■

unavailabilityoftoilets■■

thechild’spostponingdefecationbecauseheorsheistoobusy.■■

Recognising the signs to prevent functional constipation: ‘withholding’

Thepassageoflargehardstoolsthatpainfullystretchtheanusmayfrightenthechild,resultinginafearfuldeterminationtoavoidalldefecation.Suchchildrenrespondtotheurgetodefecateby(2,4):

contractingtheiranalsphincterandglutealmuscles,attemptingtowithholdstool■■

risingontheirtoesandrockingbackandforthwhilestiffeningtheirbuttocksandlegs■■

wrigglingorfidgeting■■

assumingunusualpostures■■

crossingtheirthighs■■

walkingontiptoestoclenchtheirbuttocks■■

performingtheseactionsoftenwhilehidinginacorner■■

Often parents believe this behaviour is the child attempting to defecate (4)

Eventuallytherectumhabituatestothestimulusoftheenlargingfaecalmass,andtheurgetodefecatesubsides.Withtime,suchretentivebehaviourbecomesanautomaticreaction.Astherectalwallstretches,faecalsoilingmayoccur(4),duringspontaneousrelaxationofsphincters(2)angeringtheparentsandfrighteningthechild.Afterseveraldayswithoutabowelmovementirritability,abdominaldistension,cramps,anddecreasedoralintakemayresult(4).


Fibre, fluid and exerciseSlowedcolonictransitasacauseofconstipationinchildhoodisalsowellrecognised,asistheassociationoflowfibreintakewithhard,infrequentstools(2).

Thereisastrongcorrelationbetweendietaryfibreintakeandmeandailystoolweight.Cerealfibrehasbeenfoundtoimprovebowelfunctionbyincreasingfaecalbulkandreducingtransittime,resultinginsofter,largerstoolsandmorefrequentbowelaction.

Forchildrenaged1-3yearstheaverageintakeoffibreis14g/dayand18g/dayfor4-8yearolds.Dietsrichininsolublefibre—suchasthatpresentinwholegraincerealsandbreads-areassociatedwithalowprevalenceofconstipationanddiverticulardisease(1).

Forchildrenaged1-3yearstheaverageintakeoffluidis1litre/dayandfor4-8yearoldsitis1.2litres/day.

Fibre content of foodsFood Group Food Item Fibre (grams)

Bread, cereal, rice, pasta, noodles

wholemealbread(1slice)

whitebread(3slices)

cookedrolledoats(½cup)

brownrice(1cup)

2g

BranFlakes(½cup)

muesli(2Tbsp)

Weetbix/Vitabrits(2)

4g

AllBran(≈cup)

cookedwholemealpasta(1cup)

SultanaBran(1≈cups)

8g

Fruit and Vegetables 4-5mediumprunes

½mediumapple/pear/orange

1mediumbanana

½punnetstrawberries

30gsultanas

½cuptinnedfruit

1smallpotato,peeled

1cupmushrooms

3brusselsprouts

2-3g

Legumes and Pulses½cupbakedbeans

≈cupkidneybeans8g

Nuts and Seeds 30galmonds(shelled)

60gpeanuts(shelled)

2Tbsplinseed

30gsunflowerseeds

5g


Cow’s milk protein allergyIthasrecentlybeenrecognisedthatoneofthemanifestationsofthespectrumofcow’smilkproteinallergyinearlychildhoodisconstipation(2).

Inonestudythe“relationshipbetweencow’smilkproteinintoleranceandchronicconstipationwasobserved.In28%ofthechildren,constipationdisappearedduringtheCMP-freedietandreappearedafterthechallenge”(5).

Theseresultssuggestcow’smilkproteinintolerancemustbeconsideredinthedifferentialdiagnosisofchronicconstipation’(5).‘Inchildrenunresponsivetoconventionalmedicalandbehaviouralmanagement,considerationmaybegiventoatime-limitedtrialofcow’smilk-freediet(6).

Inchildrenbetween1–4yearsofage,ahistoryofallergy,analfissureorabdominaldiscomfortmaysuggestallergytocow’smilkprotein,justifyinga2weektrialofrestrictionofcow’smilkprotein(2).

Refer to dietitian

Clinical presentation of constipationTable 16 Clinicalpresentationofconstipation(2)

First week of life Delayedpassageofmeconiumbeyondthefirst48hours,suggestseitherananatomicalobstruction,suchasanalatresiaorstenosis,orHirschsprung’sdisease

Before introducing solids

Formulafedinfantspassharderstools

Maypresentwithdifficultpassageofhardstools,occasionallyafissure

Breastfedinfantsunlikelytopresentwithhardstools,butstoolsmaybeinfrequent.Breastmilkissogoodthereisnothingtowaste(1)

Introducing solids Commonforbothbreastandbottlefedinfantstochangebowelfunctioning.Constipationmayfirstpresenthere

Toilet training Maybeassociatedwithdevelopmentofwithholdingbehaviourandfunctionalfaecalretention

AdaptedfromCatto-Smithetal(2005)(2)

Exclusively breastfed infants are rarely constipated. Many breastfed infants show signs of discomfort or distress before passing a motion: this is a normal response to body sensations they are not used to. It does not indicate pain or constipation (1)

Management of children with constipation Evidence Based Practice tip: A combination of behavioural therapy and laxatives is more effective than behavioural therapy used alone (2).

EducationBothparentandchildneedtounderstandthatconstipationandfaecalsoilingarecommon,andarelikelytoimprovewithageandsimpletherapies.Theeasiestwaytoexplainsoilingistoemphasisethelossofconsciousawarenessoftheneedtodefecatethatcomeswithchronicrectaldistensionwithfaeces(2).Theemphasison‘keepingtherectumempty’islikelytoalleviateblame,andimprovecooperationandcompliance(2)


Maintenance therapy (2)Establishingaregulartoiletingregime,generallyabout2to3timesperdayfor■■

5-10minutesatatimeaftermeals.

Ensureappropriatetoiletingpostureandcomfortablefootsupportwithfeetflat.■■

Ifdietaryfibreisdeficient,itshouldthenbeoptimised.Dietarychangesareunlikelytobe■■

helpfulifthemainmechanismofconstipationiswithholdingbehaviour.

Adiaryishelpful,andcanbelinkedtoarewardchart.Encourageparentstorecord■■

toiletingfrequency,successfulpassageofstoolinthetoilet,soilingfreedays,dailymedicationsandepisodesofsoiling.

Stool reimpaction is less likely to occur if stools are being passed daily (2).

When to refer

Referralofachildforspecialistadviceshouldbeconsideredwhen:

impaction is suspected – referral to general practitioner, hospital or paediatrician1

symptoms of constipation do not respond to treatment in general practice after 3-6 months2

there is frequent soiling and distress3

in doubt about the cause of the symptoms4

the condition is interfering with the child’s schooling or social relationships5

Relapse

A significant proportion (30-50%) of children will relapse after being successfully treated for constipation (2)

Longtermrelapseismorefrequentinchildrenunder4yearsattheonsetofsymptomsandinwhomthereisahistoryoffaecalsoilingassociatedwithconstipation(2).

Initialreviewshouldbeafter1-2weeks,thenmonthly,andeventuallyat3monthlyintervals.Maintenancetherapyandfollowupshouldbecontinuedforatleast6–24months.Atrialofweaningfromtheuseoflaxativesshouldbeattemptedat6monthlyintervals(2).Itisimperativetostresstocaregiverstheimportanceoflongtermmaintenancetherapy,includingtheuseoflaxatives.


ReferencesDietary Guidelines for Children and Adolescents in Australia incorporating the Infant 1.Feeding Guidelines for Health Workers,NHMRC,Canberra2003.

Catto-SmithAG.,(2005).Constipationandtoiletissuesinchildren.MJAPractice2.essentials–Pediatrics182(5)242-246

Breastfeeding management,3. AustralianBreastfeedingAssociation.3rdedition(2004).WendyBrodbirbb.Ligare

BakerSS,LiptakGS,CollettiRB.,CroffieJM.,DiLorenzeC.,EctorW.,NurkoS(1999)4.ConstipationinInfantsandChildren:EvaluationandTreatment.Journalofpaediatricgastroenterologyvol29(5)pp612-626

DaherS.,TahanS.,SoleD.,NapitzCK.,PatricioFRS.,Fagundes-NetoU.,MorrisMB.5.Cowsmilkintoleranceandchronicconstipationinchildren.PaedatricAllergyImmunology2001:12:339-342

2006.ClinicalPracticeGuideline:EvaluationandTreatmentofConstipationinChildren:6.SummaryofUpdatedRecommendationoftheNorthAmericanSocietyforPaediatricGastroenterology,HepatologyandNutrition.JournalofGastroenterologyandNutrition43:405-407


7.4 Failure to Thrive (Slow weight gain and undernutrition)

Failure to Thrive (FTT) has been recognised as more of a clinical description of growth failure in infants and children, rather than a stand alone diagnosis. FTT continues to be used as a blanket term for children, especially infants with perceived growth abnormalities (1). Now it is accepted that FTT has a predominantly nutritional cause, it has been suggested slow weight gain or undernutrition are reasonable alternate terms.

Themostseriousconsequencesofaninappropriatefoodintakeininfancyandearlychildhoodareunderweightandfailuretothrive.InAustralia,inrecentyears,concernabouttheprevalenceofunderweightandfailuretothriveininfancyandchildhoodhaslargelyfocusedonIndigenouscommunities,wheretheaetiologyoftheproblemrestsinacomplexmixofsocialandeconomicfactors(2).

Failuretothriveamongothersectionsofthecommunityisalsomostcommonlyaresultofpsychosocialfactors,includingpoorlivingconditions(2).

Theliteratureprovidesevidencethatfromtimetotimecasesoffailuretothrivealsooccurinmoreaffluentsectionsofthecommunityasaconsequenceofparentsinappropriatelyrestrictingthedietaryintakeofyoungchildrenbecauseoffearsaboutobesityandatherosclerosisorthedevelopmentof‘unhealthy’dietaryhabits.Suchcasesare,however,relativelyrarecomparedwiththeproblemofdietaryrestrictioninolderchildrenandadolescents(2).

Although it is now accepted that FTT has a predominantly nutritional cause, the implication of an association with emotional and physical deprivation persists (3).

There are a number of causes of failure to thrive and referral to a medical practitioner is recommended. If undernutrition is diagnosed, a dietitian/nutritionist will help in the management of this problem.

DefinitionFailuretothriveisaconditioncharacterisedbyfailure of expected growth(usuallyweight)(3,4,5).Onsetoftenoccurswithinweeksofbirthandwithhindsightgrowthfalteringisclearlyevidentongrowthchartsby6months.Failuretothriveoftenpersistsuptotheageof5years(5).

Currently,therearenonationallyorinternationallystandardisedguidelinesfordiagnosingFTT.Instudiesreviewed,chronicpoorweightgainisthemostcommonlyusedfeaturefordiagnosisfailuretothrive.Chronicpoorweightgainincludesgrowthdeviationfromtheexpectedweightpercentiles,atrend,whichmayalsobereflectedintheheightpercentiles(6).

Chronicpoorweightgainmayinclude:

inadequateweightgain■■

staticweight■■

intermittentperiodsofpoorgrowth.■■

Anadequateassessmentmustbebasedonaseriesofaccuratemeasurementsofboth length and weight.Longtermlengthandweightchangesaredesirable(refertogrowthchartsection).Head circumference shouldalsobemonitored(7).


GrowthNormal growth (1)

Growth and development represent the end product of a multitude if factors both intrinsic and extrinsic to the infant or child. Normal growth is as much dependant on the genome of a particular individual as it is the external environment in which the individual thrives. Therefore, regular routine monitoring of growth indexes represents one of the most important responsibilities facing health professionals.

Althoughnewbornsizeisdependantonintrauterinefactors,growthduringinfancyislargelynutritionallydriven.Thereistransitionfromthenutritionbasedgrowthofinfancytothegrowthhormonedependantchildhoodphase.

Factitious failure to thrive (1)

Normalgrowthishighlyvariable.Somephysiologicaladjustmentssuchasconstitutionalgrowthdelay,familialshortstatureandintrauterinegrowthretardationdonotrepresenttruefailuretothriveorpaediatricundernutrition.

Familial short stature:■■

infantshaveadecreasedgrowthvelocitybetween6and18monthspfage■■

graduallytheseinfantswillfallintoanew,geneticallypredetermined,percentile■■

afterthisdecelerationofgrowth,theyhavenormalgrowthratealongtheirnew■■

centiles

characteristicsincludenormalbirthweightandlength,butfrequentlyafamilyhistory■■

ofshortstature

infantswithnormalshortstaturehavenormalskeletalmaturation■■

Constitutional growth delay: ■■

decelerationingrowthvelocitythatoccursbefore2yearsofage,andcanbegin■■

before6monthsofage

alsoadecreaseinweightforlengthcausedbyslowgainingofweight■■

decelerationofgrowthusuallyendsby3yearsofage,followedbynormalisationof■■

growthrate,albeitbelowthe3rdcentile

familyhistoryofgrowthdelaycharacterisedbyfeaturessuchasdelayedpubertyor■■

menarcheinaparent

boysaremorecommonlyaffectedthangirls■■

increasedgrowthpotentialduringchildhood■■


Intrauterine growth retardation (IUGR):■■

infantswhoaresmallfortheirgestationalage,andtendtohaveglobalgrowth■■

retardation

catchupgrowthusuallyoccursbefore2yearsofage■■

thoseinfantsthatfailtodisplaycatchupgrowth,typicallyremainedsmall,and■■

growthproceedsveryslowly

28%to70%arebelievedtobeconstitutionallysmall,displayingtheirgenetic■■

predisposition,withtheremainderoftheinfantsexpressingIUGRcausedbyunderlyingpathologicalprocesses,andoverlappingproblemssuchasmalnutritionorsubstanceabusearerecognisedcontributors

itisimportanttorealise,byassessmentofgrowthindexes,growthrateandhistory■■

thatiugrinfantsmaybegrowingnormallywhilenotachievingcatchupgrowth

Causes of failure to thrive (3)“Traditionally,FTThasbeensubdividedintoorganicornon-organicinnature.Studieshavefound5% or less have major organicdiseases,mostlydiagnosablefromothersignsandsymptoms”(5).

Abuse and neglect■■ –Twostudieshavefoundthatbetween5-10%ofchildrenwithFTThavebeenregisteredforabuseorneglect.“However,thestudyofSkuseandcolleaguesfoundthatchildrenwithFTTwerefourtimesmorelikelytobeabusedthancontrols”(3).

Emotional■■ –doesnotappeartobestronglylinkedtoFTT(3,5)

Undernutrition■■ –MostchildrenwithFTThavebeenfoundtobesubstantiallyunderweightforheight

“Simply,thereareinadequatecaloriesforgrowthanddevelopment.Theundernourishedstateoccurseitherby,oracombinationof(1)

inadequatesupplyofcalories■■

impairedorexcessiveutilisationofcalories”■■

“It might seem puzzling that a healthy child in a loving affluent home can become undernourished. This is less so when one recognises the high energy needs of infants: approximately three times those of adults (for each kg body weight)” (3).

The fastest decline in weight gain occurs in the early weeks of life, when energy needs are the highest and the highest proportion is required for growth.

Catchupgrowthmaythennotoccurforsometime,ifsubsequentintakeismerelysufficientforimmediateneeds.Awiderangeandcombinationoffactorsmaycontributetoeitherthedeclineorthefailureforcatchup.Forexample,attheageof14months,childrenwithFTThavearelativelydelayedprogressionontosolidfoods,poorerappetitesandeatamorenarrowrangeoffoods(3).


Consequences (1,3)Growth–thenaturalhistoryofFTTisgradualimprovement■■

Cognition–evidencesuggeststhatalthoughFTTprobablyinfluencesdevelopmentin■■

theshortterm,apermanent effect on head circumference and brain growth is possible.

Primary care managementAhomevisitmightrevealobviousdietaryissuesandthisinputaloneoftenresultsinimprovement.Itiscrucialthatparentsaretoldatanearlystageandinsimpletermsthatundernutritionisthelikelycause,whileemphasisingwhatacommonphenomenonitis.

WeighingRoutineweightmonitoringatbirth,at6-8weeksandat8-12monthsaspartofroutineclinicalcare(3,5).Weightmonitoring(particularlyifconductedfrequently)canleadtoparentanxietyifababyisseennottobegainingweightfastenoughortoofast…(5)

Dietary assessment

“ A fifth of the children showed an improvement in their growth pattern immediately after dietary advice” (3).

Thepurposeoftheassessmentistoidentifypotentialareasfortailoredintervention,nottodiagnosedietaryinsufficiency.

AfirmgraspoftheenergybalanceequationisessentialforthesuccessfulmanagementofFTT.Howevermuchfoodachildappearstobeconsuming,iftheyareunderweightforheightandfailingtogainweightattheexpectedrate,orfailingtocatchup,theyarenotconsumingsufficientfortheirneedsandadviceonenergyenhancementisrequired(3).

ToddlerswithFTToftenhavealowintakeofimmature,lowenergyfoods,withahighfluidintake.Thustheaimofmanagementistoexpeditetheirprogressionontomoreenergydensesolidfoods.Liquidsupplementsortubefeedingmerelydelaythis,whereashospitaladmissionexposeschildrentotheriskofinfectionandfurtherdisruptiontoroutines.Thedramaticgainsthatcanbemadeathomeinresponsetoadviceandsupportaloneareoftennotappreciated(3).

The role of the general practitioner / paediatrician Ifmedicalcausesaresuspected,investigationsshouldbeundertaken.Mosttestsareundertakentoexcludepathologyratherthantoarriveatadiagnosis.

Improvement in growth should be evident approximately 1-3 months following initiation of treatment (5) SeeTable18onfollowingpage.


Table 18 Possiblestrategiesforincreasingenergyintake

Dietary ■✔ Small,frequentmeals:aimforthreemealsandtwotothreesnackseachday

■✔ Increasenumberandvarietyoffoodsoffered

■✔ Increaseenergydensityofusualfoods(forexample,addcheese,margarine,andcream)

■✔ Decreasefluidintake,particularlycarbonateddrinks

Behavioural ■✔ Offermealsatregulartimes,eatenwithotherfamilymembers

■✔ Praisewhenfoodiseaten

■✔ Gentlyencouragechildtoeat,butavoidconflict

■✔ Neverforcefeed

AdaptedfromWright,2000(3)

Itmustbestressedagainthattheintroductionofsolidsandtherateatwhichacceptanceandprogressionofsolidsoccurs,isverymuchmoderatedbytheindividualchildandhis/herparticulardevelopmentalpatterns.

Checklist for failure to thrive (adapted from 6)If the infant is breastfed

YES NO

Ishe/shefeedingwell?(iepositionandattachment)

Ishe/shefeedingfrequently(8-12feedsperday)

Isthereadequatemilksupply?

Doestheinfanthavereflux■■

vomiting■■

diarrhoea■■

Doestheinfanthave‘normal’bowelmotions

Istheinfantpassingadequateurine?(6-8wetclothnappiesor4wetdisposablenappiesaday)?

AdaptedfromTuckertalk2003


If the infant is bottlefed

YES NO

Istheinfantformulabeingmadeupcorrectly?

Isthecorrect(adequate)volumeofformulabeinggiven?

Doestheinfanthavereflux■■

vomiting■■

diarrhoea■■

Doestheinfanthave‘normal’bowelmotions

Istheinfantpassingadequateurine?(6-8wetclothnappiesor4wetdisposablenappiesaday)?


If the infant is taking solids (tobeusedinconjunctionwitheitherthebreastfedorformulafedsections)

YES NO

Havesolidsbeenintroducedatanappropriateage(around6months)

ArethesolidsappropriatefortheageoftheinfantCerealproducts■■

Meats■■

Fruits■■

Vegetables■■

FeedingscheduleNumberofsolidfeeds/daySolidsofferedbeforeorafterfeeds

Additionalfluidsoffered?Type__________________________■■

Quantity_______________________■■


Older children

YES NO

Areavarietyoffoodsfromthefivefoodgroupsbeingeaten?

Isthechildbeingofferedregularmealsatstructuredtimes?

Isfoodbeingdisplacedbycordials,fruitjuicesandcarbonateddrinks?

Doesthechildhaveabnormalbowelmotions(diarrhoea,fattystools)?If yes, refer for a medical review

Isfoodhighinfibrebutlowinenergydisplacingotherfoods?


It is often possible to troubleshoot and solve problems associated with nutrition by working through the checklist as above.


Tips for practice:

If an infant or child is not experiencing any difficulties with any of the previous checklist points and there is no medical reason for the failure to thrive according to medical examinations, but is still not gaining weight, it may simply be that the infant requires more food.

Thisisaspecialsituationandrequiresadditionalthought.Extraenergycanbeaddedbyofferingahighenergy/highproteinmealplanusingtherecommendationsinthenextsection.

If unsure refer to dietitian for assessment and advice.

ReferencesJolleyC.D.,FailuretoThriveCurrProblPediatrAdolescHealthCare2003;33:183-2061.

Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant 2.Feeding Guidelines for Health Workers,NHMRC,Canberra2003

WrightC.M.,Identificationandmanagementoffailuretothrive:acommunityperspective.3.ArchDisChild2000:82:5-9

OlsenE.M.,2006FailuretoThrive:StillaProblemofDefinition.ClinicalPaediatrics45:1-64.

ChildHealthScreeningandSurveillance:2002AcriticalReviewoftheevidence.NHMRC5.[online]13thApril2007www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf

CommunityPopulationandRuralHealth(2003).6. Tuckertalk (child nutrition) fully revised.Tasmania,

ShawV.,LawsonM.,ClinicalPaediatricDietetics,1994.BlackwellSciences,London7.


7.5 FluorideFluorideisanaturallyoccurringcompoundfoundinwater,plants,rocks,soil,airandmostfoods.Ithelpsprotectagainsttoothdecay.Waterfluoridationisthemosteffectivewayforeverybodytoaccessthebenefitsoffluoride.Lessthan5%ofQueenslandwateriscurrentlyfluoridated.Encourageparents/caregiverstocheckwiththeirlocalcounciltodetermineifthewaterisfluoridated.

Toothdecayoccurswhenaciddestroystheoutersurfaceofthetooth.Theacidisproducedfromsugarbybacteriainthemouth.Fluoridemakesteethmoreacidresistantandalsohelpsrepairdamagebeforeitbecomespermanent.

Toothdecayisthesinglemostcommonchronicchildhooddisease.Queenslandchildrenhavesignificantlyhigherratesoftoothdecaythanthenationalaverage,notonlyhigherthanthenationalaverage,butworsethananyotherstate.

Fluoride and breastfeedingBreastmilknaturallycontains5–10microgramsoffluorideperlitreofmilk(optimallyfluoridatedwatercontains1000microgramsperlitre).Theleveloffluorideinbreastmilkremainssteadywhenanursingmotherdrinksfluoridatedwater.

Fluoride and formula feeding Reconstitutionofinfantformulawithfluoridatedwatermayposeaslightriskofverymildormilddentalfluorosisinchildren.Parentsshouldweighthebalancebetweenachild’sriskfordentalfluorosisandthebenefitoffluorideforpreventingtoothdecaywhenmakingadecisiononwhetherornottousefluoridatedwaterforsuchpurposes.

Fluoride guidelinesFluoridesupplementsshouldonlybeusedwhenprescribedbyadentalprofessionalandarenotrecommendedforgeneraluse.Theydonotprovidethesamebenefitasfluoridatedwaterandcanbeharmfuliftakeninappropriately.

Fluoride toothpaste should be used for tooth cleaning as below:

Table 19 Fluorideisimportanttohealthyteeth

Water supply Not fluoridated Fluoridated

Birth – 6 months As soon as teeth appear, clean them twice a day with a wet, child sized soft toothbrush without toothpaste.

6 – 18 months Clean teeth twice a day with a low fluoride paste.

Clean teeth twice a day with a wet, child sized soft toothbrush without toothpaste.

18 months – 5 years Clean teeth twice a day with low fluoride paste.

6 years and over Clean teeth twice a day with standard fluoride paste.

AdaptedfromFluoridescriptpad.ForcopiescontactQHOralHealthUnit [email protected]


Useful websites and resourcesTakingcareofyourbaby’steeth–childhealthfactsheetwww.health.qld.gov.au/phs/documents/cyhu/28096.pdf,

QHWaterFluoridationQuestionsandAnswerswww.health.qld.gov.au/oralhealth/documents/30265.pdf

InformationBulletinforcommunity.FluoridationofwatersuppliesandyourHealth,QueenslandHealth:OralHealthUnit,2005

www.health.qld.gov.au/phs/documents/ohu/30268.pdf

QueenslandHealth.Waterfluoridation:helpsprotectteeththroughoutlife

QueenslandHealth:OralHealthUnit,2005www.health.qld.gov.au/oralhealth/documents/31293.pdf

QueenslandHealthWaterfluoridation:informationforhealthprofessionals.QueenslandHealth:OralHealthUnit,2005www.health.qld.gov.au/fluoride/health_professionals.pdf.

QHfluoridefactsheetwww.health.qld.gov.au/phs/Documents/ohu/21922.pdf.

ThehealthofQueenslandersCHOreport2006www.health.qld.gov.au/cho_report/documents/32048.pdf

[email protected]


7.6 GastroenteritisGastroenteritisisthetermusedtodescribeacute,infectivediarrhoeaandiscommonlycausedbypathogenssuchasviruses,bacteriaandparasites.Themostcommoncauseofgastroenteritisinchildrenlessthan2yearsisRotavirus;however,itisrarelyseenininfantslessthan6monthsofage.Aninfantorchildwithgastroenteritismostoftenpresentswithvomitinganddiarrhoea.Diarrhoeaisdefinedasanincreaseinthefrequency,fluidityandvolumeofstools.Thegastrointestinallossofwaterandelectrolytesaccompanyingthisisthemostcommoncauseofdehydrationininfantsandchildren.Themorewateryandfrequentthediarrhoea,thegreatertheriskofdehydration(particularlyifvomitingisalsoassociated).

ManagementAchildwhohasdiarrhoeaand/orvomitingisatriskofdehydrationandshouldbeseenbyadoctor.Donotgivemedicinestostopvomitingordiarrhoea.

Solely breastfed

Continue breastfeeding (there is no need to cease feeding).■■

Ensure fluid and electrolyte losses are recovered by either:■■

Increasing the frequency of breast feeds■■

Offering additional clear fluids such as cooled, boiled water between feeds■■

Formulafed

Continue normal strength formula feeds.■■

Ensure adequate hydration/rehydration by offering extra clear fluids.■■

If formula feeding has been stopped reintroduce formula after 24 hours.■■

Solids

Reintroduce food within 24 hours even if diarrhoea has not settled.■■

Ensure adequate hydration/rehydration by offering extra clear fluids.■■

Suitable foods include bread, potatoes, rice, noodles, vegetables, plain meats, fish and ■■

eggs.

Consult a doctor if one or more of the following applies:

theinfantislessthan6monthsofage■■

diarrhoeaisprofuseeg8–10waterystools■■

diarrhoeaorvomitinglastslongerthan24hours■■

theinfantorchildisvomitingandcannotkeepfluidsdown,willnotdrink,orhasnot■■

passedurinein4–6hours

thereisstomachpainorbloodinthediarrhoea■■

thereisapersistenthighfever>39.5■■ oC.


It is essential, when treating gastroenteritis to:

Ensurethattheinfant/childremainshydratedbycorrectingandpreventingfurtherlossesoffluidsandelectrolytes.

Reintroducefoodsassoonaspossibleinordertopreventprolongednutritionaldeficit.

Researchhasshownthatrefeeding,soonerratherthanlater,reducesthedurationofdiarrhoealdisease.

Signs of dehydration (1)Mild –5%bodyweightloss,thirsty,alert,restless,otherwisenormal

Moderate–6–9%bodyweightloss,thirsty,restless,lethargicbutirritable,rapidpulsenormalbloodpressure,sunkeneyes,sunkenfontanelle,drymucousmembranes,absenttears,pinchedskinretractsslowly,decreasedurineoutput

Severe–10%ormorebodyweightloss,drowsy,limp,cold,sweatycyanoticlimbs,comatose,rapidfeeblepulse,lowbloodpressure,sunkeneyesandfontanelle,verydrymucousmembranes,pinchedskinretractsslowly,nourineoutput.

Recommended hydration strategies for the dehydrated child

If a child is dehydrated medical attention should be sought.

Oral Rehydration Solution (ORS):

Arethebestcleardrinksforbabies(ofanyage)andchildrenwithgastroenteritisbecause:

theyhavetherightamountsofsugar,saltandwatertobeeasilyabsorbedinthegut■■

mustbemadeexactlyaccordingtodirectionsinthepackage■■

include■■ Gastrolyte, Gastrolyte-R, Pedialyte, Repalyte (New Formulation) and Hydralyte**(iceblocks)

availablefromchemistsinAustralia.Alwaysaskthepharmacistwhichonewouldbe■■

best

thesesolutionsarethefluidofchoicefortreatingdehydration.Theabsorptionofglucose■■

andsodiumislinkedtogetherandactsasapump,promotingtheabsorptionofwater.Theysupplyfluid,glucose,andhelpcorrectelectrolyteimbalances.ItisbesttoprovideORSinsmall,frequentdoses10–20mlevery10minutes

reviewchildafter24hoursforrehydrationstatus.■■

Please refer to:

QueenslandHealth,SouthernZonepaediatricsparentinformation–gastroenteritisinchildrenqheps.health.qld.gov.au/twmba/Pdf/SZ_gastro_fact.pdf


Recommended hydration strategies for the non-dehydrated child

Usual maintenance fluids per hour is on a sliding scale:

First10kg4ml/kg/hr.Next10kg2ml/kg/hr.

Everykgover20-1ml/kg/hr.

Forexample-fora30kgchild(40ml+20ml+10ml)=70mlperhour.

Givesmallamountsfrequently.

Full strengthfruitjuice,lemonade,cordialandsportsdrinksshouldnotbeused.Thehighsugarcontentdrawswaterintothebowelandcanmakediarrhoeaworse.

Donotgivelowjouledrinks.

Dilution rates for fluids for use in non-dehydrated children

Cordial15mlin235mlwater

Softdrinks(notlowjoule)50mlsoftdrinkin200mlwater

Unsweetenedfruitjuice50mlfruitjuicein200mlwater

ORSreconstitutedasdirected

Sample meal planBreakfast

Cereal

Applejuice

WhitetoastwithscrapeofmargarineandVegemite

Lunch

1slicewhitebreadwithVegemite

Tinned/stewedfruit

Jelly

Dinner

Leanmeat

Mashedpotato(nobutterormilkadded)

Mashedpumpkin(nobutterormilkadded)

Gravy

Tinned/stewedfruit

Jelly

AdaptedfromWestmeadChildren’sHospital,2004(2)


Useful webstes and resourcesFact sheets

Whenyourchildissick–childhealthfactsheet[accessed2007April27]www.health.qld.gov.au/child&youth/factsheets/

GastrofactsheetCYHSA[accessed2007April27]www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=303&id=1845#6

GastrofactsheetChildren’sHospitalWestmead[accessed2007April27]www.chw.edu.au/parents/factsheets/gastroj.htm

Websites

AustralianGastroenterologyInstitutewebsite[accessed2007April27]

www.gesa.org.au/

ReferencesDepartmentofHealthandHumanServices.1. TuckerTalk Manual:keepingabreastofnutrition.Tasmania;2003.

WestmeadChildren’sHospital;JamesFairfaxInstituteofPaediatricNutrition.2. The feeding guide: a handbook on the nutritional composition of infant formula.Sydney:WestmeadChildren’sHospital;2001.

DepartmentofNutritionandDietetics;MaterChildren’sHospital.Gastrochildren’s3.guidelines.Brisbane.

GutFoundation.4. Diarrhoea in children.Randwick,Sydney:TheFoundation.


7.7 Growth charts

Growthhasbeenusedasatooltoassessthehealthstatusofpopulationsandindividuals.Growthisacommonmeasureofphysicaldevelopmentandnutritionalintake,andachangeingrowthmayleadtonutritionalintervention.Thegrowthofanindividualiscomparedwith‘expectedgrowth’andconclusionsaredrawnabouttheindividualandinterventionsconsequentlyplanned.

Understandingtheapplicabilityandinterpretationofthegrowthchartsisessentialinaccuratelyassessinggrowth.Thisisimportantbecausethepatternofgrowthisdifferentbetweenabreastfedinfantandaformulafedinfant.

Inthefirst6monthsbreastfedbabiesaretypicallyheavierthanformulafedbabies.Comparedtobreastfedbabiesofthesamepercentile,formulafedbabiesarelighterinthefirst6monthsandbecomeincreasinglyheavierfrom6monthstoapproximately18months.Becauseformulafedinfantsareheavierafter6months,itisacommonmistaketomisdiagnosebreastfedinfantsashavingcompromisedgrowth.

Types of chartsTherearecurrentlyanumberofgrowthchartsavailableforuseinAustralia.Thetablebelowdescribesthem.Atthetimeofprinting,QueenslandHealthisreviewingthegrowthchartstobeused.CurrentlytheCDC2000chartsarepublishedinthepersonalhealthrecord.

Table 20 ComparisonofCDC2000andWHOgrowthcharts

Chart Presentation Data source Endorsement

CDC 2000

InPersonalHealthRecord.Purple‘Pfizer’chart.Availableforclinicalchartoratwww.cdc.gov/growthcharts/

ArangeofUSstudiesincluding3cyclesofNHANESfrom1966–1994.AllsubjectsfromUSbutmixofraceandethnicity,breastfedandformulafed.Forchildren0–2years.

Currentlyrecommendedforuse.

EndorsedbyNHMRC,AustralianPaediatricEndocrinologyGroup,AustralianCollegeofPaediatricandChildHealthNurses

WHO ReleasedApril2006.

Availableatwww.who.int/childgrowth/standards/en/

MulticentreGrowthReferenceStudy1997–2003.ChildrenfromBrazil,Ghana,India,Norway,OmanandUS.Allexclusivelybreastfedfor4–6monthswithcontinuedbreastfeedingtoatleast12months.

Forchildren0–5years,thenuseofCDC2000recommended.

WHO

InternationalPediatricAssociation

AustralianMedicalAssociation

InternationalLactationConsultantsAssociation

AustralianBreastfeedingAssociation


Using growth chartsRegular and consistent growth monitoring is more important than the chart used.

Thepatternofgrowthismoreimportantthanasingleplot.Itshouldfollowthelineofthe■■

curve,irrespectiveofitscentile.

Growthmeasurementsmustbeaccuratelyrecordedonthegrowthchart.■■

Referchildrenwho,overaseriesofreadingsarenotfollowingtheshapeofthecurve.■■

Notethedifferenceinpatternsofgrowthbetweenbreastfedandformulafedinfants.

Ensurethecorrectstaturechartisused.‘Length’referstoachildlyingdown.■■

‘Height’referstoachildstandingup.Thesevalueswilldiffer.

Whentakingweightmeasurements,ensurethesamescalesareusedwherever■■

possible,theyareroutinelycalibratedandtheinfantiswearingminimalclothing.

Encourageparents/caregiverstounderstandandinterpretgrowthcharts.■■

Allowanceforgestationalageismadeforchildrenbornunder37weeks.Generallythe■■

allowanceshouldbemadeuntilthechildis2yearsofageandupto5yearsofageforextremeprematurity,forexample,lessthan28weeks.

Forexample,ifaninfantbornat32weeksgestationvisitstheChildHealthCentreat■■

8weeksofagetheweightwillbeplottedattheageof40weeksgestation.

Weight and length/heightLength/heightisamandatorycomponentofthegrowthassessment;weightismeaninglessunlessacorrespondinglength/heightisdonesimultaneously.

Action

Forinfantsunder12monthsofage,actionwillberequirediftheweightdiffersby2percentilelinesorgreatercomparedtothelength.

Poor growthWhilethereisnostandard‘cutoff’fordefiningshortortallstature,traditionallyithasbeenrecommendedthatchildrenfallingbelowthe3rdcentilebereferredforfurtherassessment.

FTTisoftendefinedasanabsoluteweightcriterion,forexample,adropbelowthe3rdcentileforweightorthe5thcentileorwhengrowthdeviatesfromanestablishedgrowthcurvefor3consecutivemonths.Thisapproachislikelytoidentifyfalsepositives,forexample,naturallysmallchildren,whilemissingnaturallytallchildrenwithaFTTissue.Ajudgementshouldbemadeaccordingtoafallonacentilechartoveraperiodoftime/visitsorwherechildren’sweightis2centilelinesless,comparedwiththeirheight.

NB: Weightgainsininfantsareoftenstep-wiseratherthanaconstantprocess;thereforethetrendovertimeismoreimportantthanindividualweights.


Overweight and obesityChildren less than 2 years

Youngchildrenwhoseweightisgreaterby2centilelinesormorecomparedtotheirlengthmayrequireinterventionandreferral.

Children over 2 years

BMI

TodeterminewhetheranolderchildisoverweightorobeseitisnecessarytocalculateBodyMassIndex(BMI)andplottheresultonanappropriateBMIpercentilechartforthechild’sageandsex.

Calculation of BMI

BMI = weight (kg) height (m)2

For example :

A2yearoldchildwhowas87cmtallandweighed13kgwouldhaveaBMIof17

BMI=13/(0.87x0.87kg/m2)

BMI=17

Thiswouldputthechildjustabovethe50thpercentileforBMI.

AchildisoverweightiftheirBMIisatorabovethe85thpercentile.Suchachildrequiresinterventionandreferral.

AchildisobeseiftheirBMIisatorabovethe95thpercentile.Suchachildrequiresinterventionandreferral.

Itisimportanttonotethatdiscussionofchildren’sweightandassociatedfoodandactivitypatternscanbeasensitiveissue.Carersshouldunderstandthatthegrowthchartisascreeningtool.Itisintendedtobeaguideofwhentotakesmallstepstomakechangesandwhentoseekfurtherguidancefromadoctororadietitian.

Head circumferenceThechildshouldbeseenbyamedicalofficeriftheheadcircumferenceis:

abovethe95thpercentile■■

belowthe5thpercentile■■

crossingthepercentilelines,eitherupwardordownwards,aftermeasurementontwo■■

separateoccasions

smallanteriorfontanelle■■

anteriorfontanellenotclosed.■■

Closureoftheanteriorfontanelleisvariablebutusuallycompleteby18months.

Anysuspectedsmallanteriorfontanellewithbossingofsutures,orsplitandseparatedsuturesoranteriorfontanellethatisnotclosedby2yearsshouldbeseenbyamedicalofficer.


ReferencesCDCGrowthCharts1.www.cdc.gov/growthcharts

WHOGrowthStandards2.www.who.int/childgrowth/standards/en/

VictorianHealthDepartment3.www.health.vic.gov.au/childhealthrecord/growth_details/index.htm

NHMRC“ClinicalPracticeGuidelinesfortheManagementofOverweightandObesityin4.ChildrenandAdolescents”and“OverweightandObesityinAdultsandinChildrenandAdolescents:AGuideforGeneralPractitioners”.www.dhac.gov.au/internet/wcms/Publishing.nsf/Content/obesityguidelines-guidelines-children.htm

NHMRC“ChildHealthScreeningandSurveillance:Acriticalreviewoftheevidence”5.(2002)www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf

Foranthropometrytechniquestandards:6.depts.washington.edu/growth/module5/text/page5a.htm

Standardmethodsforthecollectionandcollationofanthropometricdatainchildren.7.PSWDavies,RRoodveldtandGMarks(2001)CommonwealthofAustralia

OlsenEM.Failuretothrive:stillaproblemofdefinition.ClinPediatr(Phila).2006Jan-Feb;8.45(1):1-6.

BatchelorJA.Hasrecognitionoffailuretothrivechanged?ChildCareHealthDev.19969.Jul;22(4):235-240.


7.8 Healthy weightKeeping Kids on TrackThewirysun-bronzedAussieisbecomingafigureofthepast.Wearebecominganationoffatcouchpotatoes.Obesityisbringinguslifelonghealthproblems.Alifestylediseaserequiresalifestylesolution.Fortunately,thisiswithinthecapabilitiesofallAustralians(1).

Thischapterexplorestoolsyoucanuseinyourpracticetohelpcombattherisingepidemicofchildhoodobesity.

OverweightandobesityisalreadyaseriousprobleminQueensland.WhilerecentdataisnotavailableforQueensland,inAustraliabetween1985and1997thepopulationprevalenceofoverweightincreasedby60-70%,obesityincreased2-4fold(2).Theproblemhascontinuedtoworsen.Therearenowanestimated1.5millionyoungpeopleundertheageof18inAustraliawhoareoverweightorobese(3).

“New data indicates that an additional 1% of children in Australia are becoming overweight each year, which is amongst the highest rates of increase in the world” (4).

Childhoodoverweightisassociatedwithincreasedriskfactorsforheartdiseasesuchasraisedbloodpressure,bloodcholesterolandbloodsugar.OfgreatconcernistheappearanceofType2diabetesinadolescents—evenprimaryschoolchildren—withitspotentialforcomplicationssuchasheartdisease,stroke,limbamputation,kidneyfailureandblindness(3).

Themostsignificantlongtermconsequenceofobesityinchildhoodisitspersistenceintoadulthood.Overweightyoungpeoplehavea50%chanceofbeingoverweightadults,andperhapsnotsurprisinglychildrenofoverweightparentshavetwicetheriskofbeingoverweightthanthosewithhealthyweightparents.Obeseadultswhowereoverweightasadolescentshavehigherlevelsofweight-relatedillhealthandahigherriskofearlydeaththanthoseadultswhoonlybecameobeseinadulthood(3).

WHOhasidentifiedtheunderlyingcausesoftheglobalobesityepidemicas(5):

sedentary lifestyles ■■

high intake of energy-dense, micro-nutrient poor foods■■

heavy marketing of fast food outlets and energy-dense, micronutrient-poor foods and ■■

beverages

a high intake of sugar-sweetened drinks■■

large portion sizes■■

Obese children are at increased risk of:

hyperlipidemia■■

hypertension■■

abnormal glucose tolerance■■

psychosocial problems ■■

adult obesity (6)■■


The 1995 Australian Nutrition Survey indicated that children aged 4-7 years had excessively high fat intakes, one third ate no fruit and one fifth ate no vegetables on the day of the survey (2)

Onestudyfound“consensusamongstparentsthatobesitypreventionstrategiesneededtobeginearlyinachild’slife,longbeforetheyreachedtheschoolsetting.Parentsrecognizedthatbehaviorsareshapedearlyinlifeandwerelargelyalreadyentrenchedbythetimechildrenreachedschoolage”(8).

Defining overweight and obesity in children

An Australian expert working group identified body mass index (BMI) as the most appropriate clinical measure of excessive weight in children (9)

It is essential for height and weight to be accurately measured to determine if a child is overweight or obese. Visual assessment should be avoided.

About the BMI for children BMI = weight (kg)

height (m)2

AlthoughtheBMInumberiscalculatedthesamewayforchildrenandadults,thecriteriausedtointerpretthemeaningoftheBMInumberforchildrenandteensaredifferentfromthoseusedforadults.Forchildrenandteens,BMIage-andsex-specificpercentilesareusedfortworeasons:

theamountofbodyfatchangeswithage■■

theamountofbodyfatdiffersbetweengirlsandboys■■

TheCDCBMI-for-agegrowthchartstakeintoaccountthesedifferencesandallowtranslationofaBMInumberintoapercentileforachild’ssexandage.Foradults,ontheotherhand,BMIisinterpretedthroughcategoriesthatdonottakeintoaccountsexorage(11).

Table 21 NHMRCcurrentclassificationsforBMIpercentileranges(13)

Weight status category Percentile rangeOverweight 85thtolessthanthe95thpercentile

Obese Equaltoorgreaterthanthe95thpercentile

How is BMI calculated and interpreted for children and teens?

(adaptedfromCentersforDiseaseControlandPrevention)

CalculatingandinterpretingBMIinvolvesthefollowingsteps:

Before calculating BMI, obtain accurate height and weight measurements.1

Calculate the BMI; weight (kg) / [height (m)]2 2

Plot the BMI on the appropriate chart to determine the percentile 3

Review the calculated BMI-for-age percentile and results 4

Find the weight status category for the calculated BMI-for-age percentile as shown in BMI 5 table (see table 1). These categories are based on expert committee recommendations

ABMIcalculatorcanbefoundat apps.nccd.cdc.gov/dnpabmi/Calculator.aspx


Nutrition strategiesFood language: everyday vs sometime foods

Thelanguageweusewhencommunicatingaboutfoodisveryimportant.Oftenwedescribehighcaloriefoodasverynegative.Wordslike“junk’/‘bad”canbeguiltinducingandmaybringupfeelingsofnegativityandfailure.Amorepositiveandhelpfulapproachistousetermssuchas“sometimes” foods and “everyday/always” foods.Thisdescribesfoodsmoreaccuratelyandprovidesabasisforlanguagearoundfoodchoices(1).Encourageparentstousethisformoflanguagewhendiscussingfoodchoiceswiththeirfamily.

Energy balance

Offeringasimpleconcepttoexplainenergyimbalanceasthecauseofoverweightisoftenignoredasmoreglamorous/novelideascapturepeople’sattentionandtheirmoney.Unfortunately,theseexplanationsareoftenscientificallyunfoundedandcauseconsiderablyconfusionbutdosellalotofbooks. Weallknowsomeonewhoisoverweight.Uponreflection,thispersonmaynotseemtoeatexcessively.Manychildrenweseeformanagementofobesityeatonlyslightly in excess oftheirdailyrequirements.

Sowhyisitthattheyareveryobesewhentheyonlyeatasmallamountofextracaloriesperday?Theanswerislikegettinginterestinabankaccount.Smallamountsovertimeadduptolargeamountsintheend.Forexample,imagineifsomeoneate2levelteaspoonsofextrafatperday(10g).Overayearthisaddsupto3.5kgofexcessweight(10gX365days).Keepthisupfor5yearsandallofasuddenyouhaveachildwhois17.5kgovertheirexpectedweight.Obesityresultsfromsmallamountsofexcessenergyeachday.Evenifchildrenleadveryactivelives,itiseasierforthemtocollectmoreenergythantheyexpendthroughexercise(1).

Sometimestheaimforchildrenistomaintaintheirweightsothatwhentheygrowtallertheywillthenbeinproportion.Howeverattimeslosingsomeexcessweightisnecessary.Thequalityoffoodweconsumecanhavealargeimpactonourweight.Itisimportanttounderstandthatthebuildingblocksoffood,fat,proteinandcarbohydrate containdifferentamountsofkilojoules(1).Theseare:

Fat: 37 kilojoules per gram ■■

Protein: 17 kilojoules per gram ■■

Carbohydrate: 16 kilojoules per gram ■■

Satisfying appetite

Researchhasshownthattheabovenutrientsdonotsatisfyourhungerinthesameway.Fattyfoodshaveonlyaweakeffectonsatisfyingourappetite.Incomparison,certaincarbohydratefoodshavebeenshowntohaveamoresatisfyingeffectontheappetite(1).Formoreinformation,contactyourlocaldietitian.

NB:Itisimportanttorememberthatchildrendoneedsomefatsintheirdietforgoodnutrition.

TheAustralian Guide to Healthy Eatinghasbeendevelopedtoprovidepeoplewithpracticalapplicationstoachievedailyenergybalances.Additionally,itmaximisestheamountofvitaminsandmineralsconsumed.Usethisasyourevidencebasedtoolwhenprovidingnutritioninformationtoparents.


Energy inPortion sizes

Itisimportanttoemphasisethecorrectportionsizeswhendiscussingwithparentshealthyeating.Portionsizeshavebeenincreasingoverthepastdecades,driveninpart,bycompaniesprofitingfromaperson‘upsizing’.Plates,bowlsandglassesarenowbigger,requiringmorefoodtofillthem.Snackfoodsareavailableinavarietyofincreasingsizes.UtiliseTheAustralianGuidetoHealthEatingasyourevidencebasedtooltoadviseparentsofcorrectportionsizes.

Every little bit extra contributes to energy in. Being more concise with portion sizes is a good place to start when looking at improving a child’s diet.

Energy dense foods

Manyfoodsarepre-packaged,readytoeatandloadedwithcaloriesforconvenienceandtaste.Compareyourselftosomeonewhomayhavelivedmanyyearsago.Theymighthavehadtoworkthefieldwithahorsedrawnplough,sowseedsbyhand,harvesttheseedswithascythe,threshtheseedsbyhand,milltheseedsintoflourandthenbaketheminawoodfiredoven.Theywouldalsohavetochopandtransportthewoodanddoothertasksintheirsparetime(1).

Thispersoncouldeat20loavesofcaloriedensebreadinadayandstillnotbecomeoverweightbecausetheyburnedmoreenergythantheyconsumed.Thisenergybalancehaschangedforusandproducedanepidemicofobesity.Wearenowpayingthepricefortheimbalancewithourhealth(1).

92% of children less than five years of age consume takeaway food regularly (6).

OnestudyfoundmanyAustralianchildren“weregenerallywellinformedaboutthehealthvalueofdifferentfoods,couldidentifythehealthyandunhealthyfoodspictured,andwereawareofthenutrientscontributingtotheirperceptionoffoodsbeingmoreorlesshealthy”(8).

“Parentsbelievedtheirchildrenknewwhichfoodswerehealthy,butsuspectedtheydidnotfullycomprehendtheconsequencesofeatingunhealthyfoods….Theypostulatedthattheinconsistentmessagesaboutunhealthyenergy-densefoods,includingattractivemarketingandadvertisingstrategies,confusedchildren”(8).

Parentsthemselves,althoughgenerallywellinformed,requestedmoreparenteducation…theydidnotfeelwellequippedtodistinguishbetweenmoreandlesshealthypre-packagedsnacksinlightofthehugearrayavailableandmarketedtochildren.“There’s so much deception in marketing, it’s hard to know which snacks are healthy”(8).

Food labels Bylaw,foodlabelsinAustraliamustcontainanutritioninformationpanelandaningredientslist.Youcanencouragefamiliestodotheirowninvestigatingwhentryingtoascertainwhetherfoodsareeverydayfoodsorsometimesfoods,byusingthefollowinginformationsheets.

Ingredient list

Thisliststheamountofingredientsbyweightindescendingorder(highesttolowest).Soifthefirstfewingredientslistedarefatorsugar(seebelowforothernamesforthese),thenitisoneofthemajoringredientsintheproductandthereforelikelytobehighinenergy.

Nutrition information panels

Allmanufacturedfoodsneedtocarryanutritioninformationpanel.Thisshowstheamountofenergy(inkilojoules),andnutrientcontentincludingprotein,totalfat,saturatedfat,carbohydrateandsugars,aswellasanyothernutrientthataclaimhasbeenmadeabout(eg:iron,calcium,fibre)inmeasurementsperserveandper100grams.


Whencomparingnutritioninformationpanelsitmaybehelpfultoconsider(1):

Overallenergy■■

Fatcontent:■■

lowfatmeans <3gper100gsolidfoodor■■

<1.5gper100mlliquidfood.

Sugarcontent:■■

aimfor <10gsugarper100g■■

Fibre:■■

aimforthehighestfibrecontent.■■

Itmaybeusefultocompareproductsbyusingthe“per100g”columnasservesizescanvarybetweenproducts.

Parentfactsheetsavailable

www.health.qld.gov.au/eatwellbeactive/documents/fact/reading_food_labels_fact_sheet.doc

High fatMostchildrendonotneedlowfatdiets.However,snacksthatarehighinfatandlowinothernutrientstendtotakeawaychildren’sappetitesforthemorenutritiousfoodstheyneed.

Insomecaseshowever,ahighfatfoodwillcontainothernutrientsessentialforgrowth.Thesefoodsshouldstillbeincludedinchildren’sdiets,eg.cheese,peanutbutterandavocados.

Thefatcontentsofvariouspopularchildren’sfoodsareshowninthetablebelow.

Table 22 Comparisonoffatcontentofvariousfoods

High fat food Approx fat content (%)

Lower fat alternative Approx fat content (%)

Potatocrisps 30 Vegemiteoncrackers 3

Chocolate 30 Bread,breadroll,bunloaf,fruittoast 3-4

Mostsmallsavourybiscuits 25 Ricesnacks,cornthins 3-4

Shortbreads,creamfilledbiscuits 20-25 Englishmuffins 4

Cheerios,frankfurts,salamisticks 20 Leanmince,chickenbreast,leg

ham 2-7

Chocolatecoatedmueslibar 20 Wholemealfruitbar 8

Fruitmueslibar 15 Fruit 0

Plainsweetbiscuits 15 Scone,pikelet 10

AdaptedfromWhat is Better Food? 2002.


High sugarFoodshighinsugarcantakeawaychildren’sappetitesformorenutritiousfoodsandcancontributetotoothdecay.Itisnotonlytheamountofsugarinfoodsthatshouldbelookedatwhenconsideringchildren’steeth.Foodsthatarestickyorthatwillclingtochildren’steetharemuchmorelikelytocontributetotoothdecay.

‘Noaddedsugar’doesnotindicatethatafoodislowinsugar.Itjustmeansnoextrasugarisaddedtotheproduct.Itmaybenaturallyhighinsugarsuchasinnoaddedsugar,100percentfruitjuice.

Table 23 Comparisonofsugarcontentofvariousfoodsanddrinks

Food or drink Actual serve size

Approximate amount of sugar consumed

Dri

nk

Softdrink 1 can

(375 ml)

40g=10teaspoons

Cordial 1 cup

(250 ml)

20g=5teaspoons

100%fruitjuice,noaddedsugar

1 cup

(250 ml)

18g=4½teaspoons

Water 1 cup

(250 ml)

0

Foo

d

Driedfruitbars

Processedfruitstraps

20g 13-15g=3-4teaspoons

Mueslibars 35g bar 7-10g=2–2½teaspoons

Chocolate 60g bar 33g=8¼teaspoons

Fruitloaf 2 slices 9g=2teaspoons

Bread 2 slices 2g=½teaspoon

Note1teaspoonsugar=4g

AdaptedfromWhat is Better Food?

The Infant and Child Nutrition in Queensland Report found “over half (55%) of all children under two years of age had ever been given sweet drinks regularly. In children less than one year, 15% had been given sweet drinks regularly” (6).


Snack food dilemmasAdaptedfromWhat is Better Food?

Belowissomenutritioninformationaboutfoodproductsthatoftenappearinlunchboxes,orusedassnacks.Wegenerallyknowthatfoodssuchaschocolateandpotatochipsarenotsuitabletoberegularlyincludedinchildren’slunchboxes.However,therearemanyfoodsthatchildrenbringwhereitishardertodecide.

Dried fruit bars and fruit straps

Thesedocontainsomedriedfruitbutaregenerallyveryhighinaddedsugar,lowinfibreandclingtochildren’steeth.Theyarenotcomparabletofreshfruit,despitetheadvertisingclaims.Theymayreducechildren’sfruitintake,takeawaytheirappetitesandcontributetotoothdecay.

Recommendation:Notrecommended.

Dried fruit

Driedfruitcontainssimilarnutrientlevelsandfibretofreshfruit.However,becausewaterhasbeenremoved,driedfruithasmoreconcentratedsugarandwillclingtoteeth.Driedfruitisrecommended,butisbesteatenjustpriortobrushingteethoratmealtimeswhenotherfoodsarebeingeaten.Givingdriedfruitaloneformorningteameansitwillremainonchildren’steethforsometimebeforeitisremovedbybrushingorbyeatingotherfoods.

Recommendation:Recommendedatmealtimesorwithotherfood.

Small oven baked savoury biscuits

Companiesarenowtargetingchildrenwiththesesnacksandareprovidingthesebiscuitsinsmall,convenientpackets.Manyparentsthinkthatsmallsavourybiscuitsareahealthieroptionthanpotatochipsfortheirchild.Howevertheyareoftenashighinfatandsaltasregularpotatochipsandcaneasilytakeawaychildren’sappetitesforthemorenutritiousfoodstheyneed.

Recommendation:Notrecommended.

Noodle snacks

Two-minuteareveryhighinfatasthenoodlesareusuallydeepfriedinoilpriortopackaging.Theflavouringisalsoveryhighinsalt.

Recommendation:Betteralternativesincludefat-freeAsianororientalnoodles.Theseareverytastywhenaddedtostirfrymeatandvegetables,ie.leftovers.Checktheingredientlistforfatoroil.

Muesli bars and breakfast bars

Mueslibarsarepopularwithchildrenandareoftenfoundinchildren’slunchboxes.Theyvaryinflavour,textureandnutritionalcontent.Ingeneral,chocolatecoatedorchocolatechipmueslibarsareveryhighinfatandsugar.Chewymueslibarsclingtochildren’steethandcancontributetotoothdecay.Snackbarsmadefromchildren’sbreakfastcerealsarealsoveryhighinsugarandwillclingtoteeth.

Recommendation:Chocolatecoated,chocolatechipandchewymueslibarsarenotrecommended.Children’sbreakfastcerealbarsshouldalsobelimited.Adultbreakfastcerealbarsareabetteralternative.Ifthesefoodsarebroughtalongtheyshouldbeeatenwithotherfoodsandteethbrushedaftereating.


Flavoured milk

Dairyfoodshavepropertiesthathelpprotectteethagainsttoothdecay.Flavouredmilkhasaddedsugarbutisstilldesirable,asitisanimportantsourceofcalcium.Somechildrenwillnotdrinkplainmilk.Childrenenjoythevarietythatflavouredmilkprovides.Itisimportantthatchildrenreceiveanadequatecalciumintakeanddrinkingmilkisoneoftheeasiestwaystoachievethis.

Recommendation:Allmilkisrecommended.

Fortoddlersover12monthsofageplain,fullcreammilkispreferredandforchildrentwo■■

tofiveyearsofagereducedfatmilks(1.5-2.5%fat)shouldbeused.

Skimmilk(lessthan0.5%fat)shouldnotbeuseduntilchildrenareoverfiveyears.Itis■■

finetohaveflavouredmilkoccasionally.

Makesuremilkconsumptiondoesnotexceedrecommendationsforage.■■

Flavoured dairy desserts

Yoghurtistheidealdairydessertforchildren.Itismoderateinsugarandfatandhighincalciumandprotein.Reducedfatvarietiesarerecommendedforchildrenoncetheyareovertwoyearsofage.Therearemanyflavoureddairydessertsmarketedforyoungchildren.Thesevaryintheirfat,sugarandcalciumcontents.Comparedtoyoghurt,dessertswhichhave‘mix-ins’are,ingeneral,muchhigherinsugarandsometimeshigherinfat.Thisisalsothecasewiththemajorityofchocolatemousseandcrèmecarameldesserts.Popularcustardbasedflavoureddessertsaregenerallyhigherinsugarthanyoghurtandtheyvaryintheircalciumcontent.Thesearenotabadchoiceifchildrenwillnoteatyoghurtandcanbeavaluablewayofimprovingcalciumintakes.

Recommendation:

encouragefullcreamflavouredorunflavouredyoghurtinpreferencetootherproducts■■

usethenutritionpanelofyoghurttocomparethevariousproductsthatappearin■■

children’slunchboxes

discourageyoghurtwithmix-inlolliesandhighfatdesserts,likechocolatemousse.■■

Cheese and biscuit snacks

Thesearepopularinchildren’slunchboxesandareagoodsourceofcalcium.Ratherthanthepre-packagedvarieties,wrappingupsomecrackersandasliceofcheeseinplasticwrapforthelunchboxreducescostandpackaging.

Recommendation:Recommended.

Biscuit and dip packs

Manydifferenttypesofbiscuitanddippacksexistforchildren.Somedipsarecheese-basedandareagoodsourceofcalcium.Thesweetflavoureddipsnackpacksareveryhighinsugar.

Recommendation:Cheeseorcheddardippacksarerecommendedbutsweetflavoureddipsnackpacksarebetterleftout.

Jam, honey or chocolate paste sandwiches

Thebreadisahealthychoicebutjam,honeyandchocolatepasteprovidesugarwithfewothernutrients.Childrenneedagoodsourceofironeachday.Thefillingonsandwichesisusuallytheeasiestwaytoprovidethis.

Recommendation:JamandhoneyareOKtohaveoccasionally,buttrytoencouragehighironfoodseg.roastmeat,chicken,ham,tuna,egg,peanutbutterorbakedbeans


Energy outKids sport and technology

Energyexpenditurethroughphysicalactivityisanimportantpartoftheenergybalanceequationthatdeterminesbodyweight.Adecreaseinenergyexpenditurethroughdecreasedphysicalactivityislikelytobeoneofthemajorfactorscontributingtotheglobalepidemicofoverweightandobesity(5).Refertophysicalactivitysection.

Children aged 5-12 years spend an average of 2.5 hours per day watching television (2).

How much physical activity is sufficient for children?

New physical activity guidelines from the Department of Health and Ageing 2004 (4):

Children and youth should participate in at least 60 minutes (and up to several hours) of 1 moderate – to vigorous intensity physical activity every day

Children and youth should not spend more than 2 hours per day using electronic media for 2 entertainment (eg television, computer games, internet), particularly during daylight hours.

Physicalactivityhasdecreasedmarkedlyoverthelastcentury(especiallyinthelast20years).Theadventoftechnologyhasencouragedchildrentopursuemoresedentaryactivitiessuchasplayingvideogames,computers,VCRs,DVDs,CDs,andMP3s.Concernsaboutsafetyhavediscouragedparentsfromallowingtheirchildrentoplayunsupervisedinparks,streetsandneighbourhoods.Childrendon’trideorwalktoschool(1).

Young children spend more than 50% of their time in sedentary play (13).

Onestudyfoundsomechildrenviewanyamountofbodymovementconstitutedphysicalactivity;“playingpianoorcomputerisabithealthybecauseyou’removingyourfingers”(GradeTwo)(8).

Media and peer conformity

Peerpressureandwhatotherchildrenareeating/doingdirectlyimpactsuponourthinkingandexpectations.Advertisingcompanieshavebecomeverycunninginpromotingtheirproducts.Forexample,productplacementnowoccursinmovieswherecompanieswillpaytohavetheirbrandexclusivelyusedinamovie.Thisisasneakyandhiddenwaytopromoteandinfluencepeopletobuytheproduct(1).

Inthesimplestterms,obesityresultsfromanimbalancebetweencalorieseatenandcaloriesexpendedthroughactivityandexercise.Television(andmediabehaviour)upsetsthisbalancethrough:

reducedmetabolicratewhenwatchingTVandothermediaactivities■■

reducedactivitybecauseofwhattheyarenotdoingwhilsttheyareinteractingwiththe■■

media(childrenwhowatchmoreTVdolesssport)

increasedfoodandcalorieconsumption(fromadvertisingandsnacking).■■

Children are vulnerable to food messages portrayed through television advertisements, with food advertising affecting the choices and amounts of foods consumed (17).


OneAustralianstudyfound“Confectionery’and‘fastfoodrestaurants’werethemostadvertisedfoodcategoriesduringchildren’sTVviewinghours.Confectioneryadvertisementswerethreetimesaslikely,andfastfoodrestaurantadvertisementstwiceaslikely,tobebroadcastduringchildren’sprogramsthanadults’programs(17).

“Foodsmostadvertisedduringchildren’sviewinghoursarenotthosefoodsthatcontributetoahealthydietforchildren.Confectioneryandfastfoodrestaurantadvertisingappearstotargetchildren’(17).

It is well recognized that childhood obesity is a worldwide problem. The heavy marketing of energy-dense, nutrient-poor foods influences food choices and contributes to the incidence of overweight and obesity in children (14).

Checkreduce TV viewing for children and set specific limits■✔

remove TVs from bedrooms■✔

limit mobile phone usage■✔

cease cable TV■✔

reduce computer time especially chat rooms, emails, videos, video games■✔

remove electronic toys■✔

reduce and limit dvd’s movies■✔

look for product placements in media with your children ie turn sound off ■✔and guess what products have been placed in TV-movies

AdaptedfromKids on Track, 2004

Meal time tipsuse smaller plates/ bowls■✔

do not over fill plate■✔

have water available with all meals■✔

allow children to leave food on their plates■✔

minimise distractions eg TV off■✔

encourage your children to eat slowly■✔

encourage mealtime conversation■✔

eat together as a family■✔

model all the above tips yourself during the meal■✔

try these during at least one meal per day■✔

a small amount of sugar and salt per day■✔

increase plant based unprocessed foods■✔

increase high fibre foods■✔

reduce family grazing between meals and limit it to fruit and water■✔

AdaptedfromKids on Track, 2004


Table 24 Possiblecausesofachildbeingabovetheirnaturalbodyweight

Question ActionE

NE

RG

Y IN

Concerns with eating patterns?

Arefoodshighinfatandsugarbeingconsumedinlargeamountsoroftenthroughouttheday?

Encourage parents to accept their child’s ■✔ability to regulate energy intake

Restrictive diets are not recommended■✔

Promote the intake of fruit and vegetables■✔

Restrict the intake of energy-dense, ■✔micronutrient-poor foods (eg. packaged snacks)

Restrict the intake of sugars-sweetened ■✔soft drinks

Assure the appropriate micronutrient intake ■✔needed to promote optimal linear growth

What is the child drinking?

(egcordials,softdrinks,fruitjuices)

Limit juice to ½ cup per day■✔

Provide milk in sufficient amounts for age ■✔

Meet additional fluid requirements with ■✔water

EN

ER

GY

OU

T

Physical activity

Isthechildactive?

Sedentary behaviour

HowmuchTVandcomputergamesdoesthechildwatch?

Promote an active lifestyle■✔

Encourage planned exercise that the child ■✔enjoys as well as an increase in activities that involve more movement

Limit television viewing■✔

Discuss the number of hours TV is watched ■✔as it can reduce exercise levels and exposes the child to considerable food advertising

AdaptedfromWHO(2002),Tuckertalk(2003)


Useful websites and resourcesFurther reading

The Queensland Strategic Policy Framework for Children’s and Young People’s Health 1.2002 – 2007.QueenslandHealth2002

Eat Well Queensland 2002-2012, Smart Eating for a Healthier State, Queensland Public 2.Health Forum.June2002

Eat Well, Be Active – Healthy Kids for Life: 2005-20083. .QueenslandGovernment2005

Healthy Weight 2008, the National Action Agenda for Children and Young People and 4.Their Families, Commonwealth of Australia.2003.

Queensland Health, Enhanced Child Health Model of Care for Community Health Services 5.(0-12 years)

Strategic Policy Framework for Aboriginal and Torres Strait Islander Children and Young 6.People’s Health 2005- 2010

Growth charts

CentresforDiseaseControlandPreventionwww.cdc.gov/

WorldHealthOrganisationwww.who.int/childgrowth/en/

Parent resources

Eat Well, Be Activewww.health.qld.gov.au/eatwellbeactive

A note on Kids on Track

Kids on Tracktargetschildrenthreetotenyearswhodonothaveanymedicalconditionsthatmightcauseoverweight.Itspurposeistoexaminetheeffectofagroupparentinterventiononthecourseandseverityofoverweight.Ithelpsparentsaddresstheirchildren’shealthproblemsviathreekeyareasofnutrition,physicalactivityandfamilybehaviourchange.Italsoinvestigatesifpositivehealthoutcomescanbemaintained.TheseprogramsarecurrentlybeingrunontheGoldandSunshineCoastsaswellasBayside.

Forfurtherinformationpleasecontact

TheReceptionistBundallCommunityChildHealthPOBox5699GCMCBundallQLD9726Phone:0755708553


ReferencesQueenslandHealth:‘1. Kids on Track,’GoldCoast,2004

Booth,M.L.,Wake,M.,Armstrong,T.,Chey,T.,Hesketh,K.,&Mathur,S.(2001).The2.epidemiologyofoverweightandobesityamongAustralianchildrenandadolescents,1995-97.Australian and New Zealand Journal of Public Health,25(2),162-169.

CommonwealthofAustralia20033. Healthy Weight 2008, Australia’s Future,Canberra[online]29thAprilwww.healthyactive.gov.au/publications.htm

QueenslandGovernment.SmartStatehealthyweightforchildrenandyoungpeople.4.Eat well, be active – healthy kids for life.TheQueenslandGovernment’sfirstactionplan2005-2008.

JointWHO/FAOExpertConsultationonDiet,NutritionandthePreventionofChronic5.Diseases(2002:Geneva,Switzerland)Diet,nutritionandthepreventionofchronicdiseases:reportofajointWHO/FAOexpertconsultation,Geneva,28January--1February2002.[online]29thAprilwww.who.int/hpr/NPH/docs/who_fao_expert_report.pdf

QueenslandHealth:InfantandChildNutritioninQueensland20036.

Best Practice Dietetic Management of Overweight and Obese Children and Adolescents7. .AustralianCentreforEvidenceBasedNutritionandDietetics.TheJoannaBriggsInstitute[online]26thApril

Healthyeating,activityandobesityprevention:aqualitativestudyofparentandchild8.perceptionsinAustraliaK.HESKETH,E.WATERS,J.GREEN,L.SALMONandJ.WILLIAMSHealthPromotionInternational,2005,Vol.20No.1pp19-26

Batch,J.A.,&Baur,L.A.(2005).Managementandpreventionofobesityandits9.complicationsinchildrenandadolescents.MJA,182,130-135.

NationalHealthandMedicalResearchCouncil:10. Dietary Guidelines for Children and Adolescents in Australia incorporatingthe Infant Feeding Guidelines for Health Workers,Canberra2003.

CentresforDiseaseControlandPrevention11. www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm[online]2ndMay,2007

QueenslandHealth:12. What is better food? Brisbane2002

Clinical Practice Guidelines for the Management of Overweight and Obesity in Children 13.and Adolescents,NHMRC.Canberra,2003

HowmuchfoodadvertisingisthereonAustraliantelevision?KathyChapman,Penny14.NicholasandRajahSupramaniam.HealthPromotionInternational200621(3):172-180;doi:10.1093/heapro/dal021

CommunityPopulationandRuralHealth15. Tuckertalk,Tasmania,2003

online[2ndMay]16. www.culturaldata.gov.au/publications/statistics_working_group/australias_culture_pamphlets/10_childrens_participation

NevilleL.,ThomasM.,BaumanT.,FoodadvertisingonAustraliantelevision:theextentof17.children’sexposureHealthPromotionInternational2005,Vol.20No.2.pp105-112

Borushek,A.18. Pocket calorie, fat & carbohydrate counter,2007,FamilyHealthPublications,WesternAustralia


7.9 Iron deficiencyIron deficiency is the most common nutritional deficiency in children and adults in both developed and developing countries (1)

ThosemostatriskofIrondeficiencyare:

childrenparticularlyagedbetween9-18months■■

womenofchildbearingage(1).■■

As many as 10% of Australian toddlers are iron deficient (2).

Irondeficiencyinchildhooddiffersinmanywaysfromthatinadults.Inchildren,themostlikelycauseisaninadequateamountofironinthediet,coupledwiththeextrarequirementforironbecauseofgrowth(2).

The effects of anaemia and iron deficiency on brain development in infancy and very early childhood are well documented: “infancy is the critical period for brain growth, and nutrient deficiencies during this time may affect psychomotor development and neurocognition” (3). “There is some disturbing evidence which suggests that the intellectual and psychomotor impairment caused by iron deficiency may not always be completely reversible when iron status is corrected” (as cited in 2).

For these reasons, the Australian Iron Status Advisory panel strongly believes that iron deficiency should be regarded as a serious illness in the first years of life’ (2)

Irondeficiencyiscommon,butitispreventableifsuitablefeedingchoicesaremade.Exclusivebreastfeedingtotheageof6monthswillensurethatbreastmilkisnotreplacedbyfoodoflowernutrientdensityandwillminimisetheriskofirondeficiency(8).Ifformulafeeding,itisimperativeparentsorcaregiverschooseanironfortifiedcow’smilkformula.

TheRDIforinfantsagedbetween7and12monthsis11mg/day;forchildren1-3yearsofage9mg/day,andchildrenaged4-8yearsis10mgperday.Pregnancyandbreastfeedingto27mg/dayand9-10mgperdayrespectively.

Animportantaspectofpreventioniseducatingparentsaboutthechangingdietaryneedsoftheirgrowingchildandthetypesoffoodsthatarerichinironorwhichencourageironabsorptionandalsothosethatrestrictironabsorption.

Informingparentsofthetwomostcommonfactorsassociatedwithirondeficiencymayalsobeausefulpreventativeactivity.Thesetwofactorsare(1)beingfedoncows’milkpriorto12monthsofage,and(2)continuingsolelyonmilk(eitherbreastorcows’milk)after12monthsofage,withouttheintroductionofsolids.

If unsure of iron intake – refer to a dietitian for assessment and advice.

The Dietary Guidelines for Children and Adolescents in Australia recommendations

Continue exclusive breastfeeding for about 6 months■■

Introduce complementary foods containing iron at about 6 months of age■■

Choose iron-containing formula for infants who are not breastfeed and for ■■

infants receiving formulas as well as breastmilk

Delay the introduction of whole cow’s milk until 12 months of age■■

Continue to offer iron-fortified and meat containing foods beyond ■■

12 months of age


What is iron deficiency?“Ironispresentinallcellsinthehumanbody.Itsfunctionsincludethetransportationofoxygenaroundthebody,thefacilitationofoxygenuseandstorageinthemuscles….Mostironisfoundintheredbloodcellsashaemoglobin”(1).

Newbornsreceivetheirironstoresinthewomb.“6monthsofagehasbeenidentifiedasatimewhenironstoresarefallinginbothbreastandformulafedinfants”(4).“However,oncenewbornironstoresaredepleted,thechildmustmeetthebody’sironneedsthroughdietaryintake”(1).

The body’s ability to absorb iron from the diet is dependant on:

theamountofironalreadystoredinthebody(moreironisabsorbedwhentheiron■■

storesarelow)

therateofredbloodcellproduction■■

theamountandkindofironeateninthedietegironinmeatismorereadilyabsorbed■■

thanironinvegetables.

thepresenceofabsorptionenhancersandinhibitorsinthediet■■

“If there is insufficient iron in the diet or if other problems prevent dietary iron from being absorbed into the body, a child’s iron stores will become depleted” (1).

Iron deficiency occurs across a spectrum from iron depletion to anaemia.

Table 25 Definitionsofimpairedironstatus

Iron depletion

Plasmaferritinlevel<10µg/L■■

Nofunctionaldeficit(3)■■

Normalhaemoglobin■■

Iron deficiency

Irondepletionplus■■

Meancorpuscularvolume■■

<70fL(age,12-23months)or<73fL(age,24-38months)plus

Meancorpuscularhaemoglobin<22pg■■

Functionaldeficit(3)■■

Normalhaemoglobin(3)■■

Iron-deficiency anaemia

Irondeficiency■■ plus

Haemoglobinlevel<110g/L■■

Normalfunctionscompromised(1)■■

AdaptedfromCouperRetal(2001)(3)


Figure 6 Continuumofchangesinironstoresanddistributioninthepresenceofincreasedordecreasedbodyironcontent

AdaptedfromHerbertV:Anemias.InPaigeDM[ed]:ClinicalNutrition.St.Louis,CVMosby,1988,p593,withpermission.

Symptoms of iron deficiency and iron deficiency anaemia (1)Irondeficiencyinchildrencanbeasymptomatic.Clinicalindictorsmayinclude:

behaviouralchanges(lethargy,irritability,lackofconcentration)■■

cognitiveandpsychomotordeficits,■■

decreasedimmunefunction(recurrentinfections)■■

lossofappetite■■

pica(theeatingofdirt,clayorotherstrange‘foods’)■■

FTT,althoughnotspecifictoirondeficiency,shouldalwayspromptconsiderationofiron■■

status

Clinicalindictorsofanaemiaincludetheaboveand

pallor■■

inextremecases,heartfailure■■


What causes iron deficiency?

Infants

Theinfantyearisoneofrapidgrowth.Dietaryinadequaciesduringthisperiodplacetheinfantatriskofdevelopingirondeficiency.

Risk factors for iron deficiency:uncorrectedmaternalirondeficiencyduringpregnancy■■

prematurity,leadingtoinadequateaccumulationofironinthenewborn’sstores■■

agelessthan2years■■

introductionofcow’smilkasthemainsourcebefore12monthsofage■■

cow’smilkintakeexceeding600mlperday(6)■■

Common feeding practices contributing to iron deficiencyInfantsmaybedevelopingirondeficiencyifanyofthefollowingfeedingpracticesoccur(6):

useofcow’smilkinsteadofinfantformulaorbreastmilk,ininfantsunder12monthsofage■■

delayedintroductionofsolids■■

displacementofsolidfoodintakebymilk■■

prolongedbottlefeedingwithcow’smilk■■

lowmeatorhaemironintake■■

bottleuseinchildrenover12monthsofageencouragesexcessivefluidintakethatmay■■

displaceothermorenutritioussolidfoods

NB:Cow’smilknotonlyhasalowconcentrationofiron,buttheironispoorlyabsorbed(refertotoddlersection).

NHMRC states health professionals should be vigilant with their clients and assess iron status based on the above risk factors (6)

Recommendation: Commercial infant cereal is the preferred first solid food because it is iron fortified (6).

Rice cereal was the first food given to the majority (70%) of children in the findings in the Infant and Child Nutrition in Queensland Report, 2003 (7).

Toddlers and preschoolers Thesamebasicscenarioappliesinthesecondyearoflife.Themainproblemwithtoddlersistheoverrelianceonmilk:unfortunately,thislowironfoodendsupformingalargepartofthetotalfoodintake.Thesecommentsapplytoallformsofmilk,notjustcow’smilk.Goat’smilkisaparticularlypoorsourceofironandsoymilkisnotsatisfactoryeither(seetoddlersection).

Vegetarianism in infants and childrenAvegetariandietthatisadequateforadultsisnotnecessarilysuitableforinfantsandyoungchildren,whofaceconstraintssuchaslimitedstomachcapacityandhigherneedsfornutrientsperunitweight.Eachdietmustbeassessedseparatelyforitssuitabilityforchildren;iftheregimenisveryrestrictiveintermsofthetypeandamountofanimalproteinsconsumed,itisessentialtoplanadietcarefullysoastoavoiddeficiencies.

Ingeneral,lacto-vegetarianandlacto-ovovegetariandietsprovideadequatenutritioniftheyareproperlyplanned.Vegandietsposeariskifcareisnottakentoensurethatthedietprovidesadequateenergy,vitaminB12,proteinandiron(8).Referral to dietitian for assessment and advice


All ages:

Irondeficiencyresultsfromoneoracombinationoffactors,whichinclude:

inadequateoralintake■■

impairedabsorption■■

bloodloss–includingmenstrualbleeding■■

pregnancy(withoutadequateintake/oralsupplementation)■■

TreatmentAdietaryassessmentisthefirstcomponentofmanagement.Followingthis,thehealthprofessionalcanadviseparentsonwaystoincreasetheirchild’sconsumptionoffoodsrichinironandthosethatenhanceironabsorption,whilstdecreasingtheconsumptionoffoodsthathamperironabsorption.

Initiallychildrenmaybealsobeprescribedironsupplementstorepletetheirironstores(1).Parentsshouldbewarnedthatbowelmotionsareoftenblackandthatthisdoesnotdenoteillhealth.

Too much iron can be harmfulThebodystoresironveryefficiently,andtoomuchironcanbetoxic.

Haemochromatosisisaconditioncharacterisedbyexcessiveironstores(9)

Supplementation must never be given, unless under the supervision of a medical practitioner.

“ Once children become iron deficient, they become very restricted in the range of foods they will accept. Appetite and tolerance of new or previously discarded foods improves with iron repletion” (3).

Referral to general practitioner / paediatrician and dietitian


Bioavailability of ironDietaryironcomesintwoforms:

Haem iron isfoundinfleshfoodssuchasredmeat,chickenandfish.

Non-haem iron isfoundinplantfoodssuchaswholegrainbreadsandcerealsandsomevegetables.

The body absorbs:Just under one quarter of the iron contained in animal foods. ■■

Less than one tenth of the iron from plant sources■■

What are the best sources of iron? (10)Foods which contain haem iron include:

leanredmeatssuchasbeef,lambandveal.■■

offalmeatssuchasliverandkidney.■■

chicken,pork(includingham),fishandshellfish.■■

pateorfishpaste.■■

Foods which contain non-haem iron include:Iron-fortifiedbreakfastcereals(checkthelabeltoseeifironisadded).■■

Wholemeal/wholegrainbreadsandcereals.■■

Driedpeas,beansandlegumeseg.lentils,bakedbeans,soybeans,kidneybeans,tofu.■■

Leafygreenvegetableseg.spinach,parsley,broccoli.■■

Eggs.■■

Driedfruit.■■

Peanutbutterandnuts(wholenutsarenotrecommendedforchildrenunder5).■■

Tahiniandhommus.■■

Dietary factors that boost iron absorption (9)Certainfoodsanddrinkshelpyourbodytoabsorbgreateramountsofiron,including:

VitaminC(foundinfruitsandvegetablessuchas:citrusfruits,redcapsicum,kiwifruit)■■

increaseironabsorptionfrombothhaemandnohaemironsources.

Dietary factors that reduce iron absorption (9)Certainfoodsanddrinksreduceyourbody’sabilitytoabsorbiron,including:

Tanninsfromtea,coffeeandwinereduceironabsorptionbybindingtotheironand■■

carryingitoutofthebody.

Thephytatesandfibresinwholegrainssuchasbrancanreducetheabsorptionofiron■■

andotherminerals.

Checkeat foods high in haem iron■✔

eat foods high in non-haem iron, and where possible combine with haem ■✔iron to help absorption

eat vitamin C rich foods (citrus and berry fruits, tomato, broccoli and ■✔capsicum) at each meal as this further increase iron absorption


Assessing the diet – asking about iron consumption for infants and toddlersAdaptedfromtheAustralianIronStatusAdvisoryPanel2,6

First year

Wasthechildbreastfedorformulafed(iron-fortified)?■■

Whatagedidyouceasebreastfeeding■■

Whatdrinksdidyouintroduce?(iron-fortifiedformulaorcow’smilk)?■■

Solids

Atwhatagedidyouintroducesolids?■■

Werethefoodsironfortified(orweresupplementsgiven)?■■

Whendidthechildstarttoeatredmeat,chickenandfish?Howmuch?■■

Current diet

Whatdoesyourchildeatnow?■■

Whataboutfleshfoods(redmeat,chicken,fish)andplantsourcesofiron(grains,■■

legumes).

HowmanyvitaminCrichfoodsareeatenatthesametime(eg.citrusfruits,cauliflower,■■

broccoli,strawberries,melon)?

Cow’s milk

Atwhatagedidyourchildstartoncow’smilkandhowmuchisconsumed?■■

Other fluids

Whataboutthevolumeofotherfluids-otheranimalmilks,juices,cordialsandsoft■■

drinks,teaandcoffee?(Tannininhibitsironabsorption,juicesdisplaceironrichfoodsfromthechild’sdiet)


Suggestions to prevent or treat iron deficiency in pregnant and breastfeeding mums (4, 9) One and a half serves of meat, fish, poultry or alternatives each day are recommended in pregnancy and 2 during lactation. The Australian Guide to Healthy Eating recommends that red meat be eaten 3 to 4 times a week; less than this and high-iron replacement foods will be required.

Pregnancy

Eataniron-richdietduringpregnancy.Redmeatisthebestsourceofiron(seeantenatal■■

section).Chooseiron-fortifiedbreakfastcerealsandbreads.

Teststocheckforanaemiashouldbeconductedduringpregnancy.Ifyourdoctor■■

prescribesironsupplements,takethemaccordingtoinstructions.

Discussanysideeffectscausingconcernwithyourdoctor.Itisnormaltoseechanges■■

instools.

Breastfeeding

Whenbreastfeeding,ensureahealthydietisconsumed,withadequateamountsofiron■■

(seebreastfeedingsection)

Cutbackontheamountofteaandcoffeeyoudrink,especiallyaroundmealtimes,since■■

thetanninsinteaandcoffeebindtotheironandinterferewithabsorption.

Pregnancy / breastfeeding checklist

Mumincludesredmeat3-4timesaweek

Ironlevelshavebeencheckedwhilstpregnant,andmumisawareofherironstatus

Ifironsupplementisrequired,itistakenasdirected

Encouragefoodshighinnonhaemirontobeeatenwithhaemironfoods

EncouragefoodshighinvitaminCtobeconsumedwithironcontainingfoods

Limitintakeofteaandcoffee(around3aday)

Limitexcessiveintakeofbran

Ifmumisavegetarianrefertodietitian

Suggestions to prevent or treat iron deficiency in infants (4,9)

Introducing solids

Don’tgiveyourbabycow’smilkorotherfluidsthatmaydisplaceiron-richsolidfoods■■

before12monthsofage.

Startgivingyourbabypureedfoodswhentheyarearound6monthsofage.Fortified■■

babycerealmadewithiron-fortifiedformulaorbreastmilk,atfirstalongwithpureedvegetablesandfruit.Graduallyincludefinelymincedmeatatonemealtimefrom6monthsonwards.


Introducing solids with appropriate iron checklist (adapted from 4)

Babiesareexclusivelybreastfeduntil6monthsofage

Ifformulafed,ironfortifiedmilkformulaischosen

Ironfortifiedcerealshavebeenintroducedaround6months

Haemironfoods(egredmeat,chickenandfish)havebeenintroducedaround7months

Cow’smilkisdelayedasthemainmilkdrinkuntil12months

Onceavarietyoffoodshavebeenintroduced,vitaminCrichfoods(egcitrus,berries,tomatoesetc)areeatenwithhaemandnonhaemironfoods

Ifmotherand/orchildarevegetariansrefertodietitian

Suggestions to prevent or treat iron deficiency in toddlers and preschoolers (4,9)

meat,poultryandfishareimportantsourcesofironinyourchild’sdailydiet.includered■■

meat3to4timesperweek(8)

vitaminChelpsthebodytoabsorbmoreiron,somakesureyourchildhasplentyoffruit■■

andvegetables

watchyourchild’sfluidconsumption;lotsofmilkandjuicecantaketheedgeoffan■■

alreadysmallappetiteandthereforelimitintakeofironrichfoods

chronicdiarrhoeacandepleteyourchild’sironstores,whileintestinalparasitessuchas■■

wormscancauseirondeficiency.Referaltodoctorforpromptdiagnosisandtreatment.

Practical ways to increase iron in the diet for young children

includenutrientdensefingerfoodssuchasslicesofroastmeat,leftoverminimeatballs,■■

sandwicheswithcoldmeat,coldcookedsausages,coldplatterwithcookedmeatandrawvegetableswithadip

offermeatalternativesincludingdriedbeans,lentils,chickpeas,cannedbeans,fish,■■

eggsandsmallamountsofnutsandnutpastes.

includefoodsrichinvitaminclikeoranges,mandarins,berriesandtomatoes.■■

encourageyoungchildren,toddlersorfussyeaterstotrymincedmeats,fortified■■

breakfastcereals,eggsandsmoothnutpastes.

Iron in toddlers and children checklist (adapted from 4)

Smallportionsofavarietyoffoodsfromallfoodgroupsareofferedregularly

Toddlersconsumingupto600mlmilkperday(nomore)

Toddlerconsumingupto½cupofjuiceperday(nomore)

Highiron,nutrientdensefingerfoodsareencouraged

Ifconcernswithfussyeating,refertodietitian

Ifmotherand/orchildarevegetariansrefertodietitian

AdaptedfromTuckertalk,2003


Useful websites and resourcesKey state and national documents for health workers:

Dietary Guidelines for Children and Adolescents in AustraliaandInfantFeedingGuidelinesforHealthWorkers

OptimalInfantNutrition:evidencebasedguidelines

InfantandChildNutritioninQueensland2003

NationalBreastfeedingStrategy

ReportoftheChiefHealthOfficerQueensland,2006

AustralianironStatusAdvisoryPanel

www.ironpanel.org.au/AIS/AISdocs/childdocs/Ccontents.html

Further professional development reading:

SandovalC.,JayaboseS.,EdenA.N.,(2004):Trendsindiagnosisandmanagementofirondeficiencyduringinfancyandearlychildhood.HaematologyOncolClinNAm18(2004)1423-1438

Parent handouts:

ChildHealthInformationFactSheetswww.health.qld.gov.au/child&youth/factsheets/

www.health.qld.gov.au/cchs/Gen_Nutrition_Activity/whyiron.PDF

BetterhealthChannel;VictorianGovernment

www.chw.edu.au/parents/factsheets/iron.htm

GrowingStrong:Feedingyouandyourbaby

ReferencesChildHealthScreeningandSurveillance:2002AcriticalReviewoftheevidence.NHMRC1.[online]13thApril2007www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf

[onlineApril2007]2. www.ironpanel.org.au/AIS/AISdocs/childdocs/Ccontents.html

CouperR.,andSimmerK.3. Iron deficiency in children: Food for thought.MJA2001;174:162

Tuckertalk:TheFamilyNutritionEducationManual.DepartmentofHealthandCommunity4.Services,Tasmania.2004

CouperR.,andSimmerK.5. Iron deficiency in children: Food for thought.MJA2001;174:162

KruskeS.,NorbergM.,StewartL.,MillenL.2004.‘FeedingPracticesandIronDeficiency6.inChildrenunder2yearsofage:CentreforFamilyHealthandMidwifery,Sydney

QueenslandHealth:RosGabriel,GaylePollard,GhazalaSuleman,TerryCoyneandHelen7.Vidgen.InfantandChildNutritioninQueensland2003.QueenslandHealth.Brisbane2005.

NationalHealthandMedicalResearchCouncil:8. Dietary Guidelines for Children and Adolescents in Australia incorporatingthe Infant Feeding Guidelines for Health Workers,Canberrawww.health.gov.au/pubhlth/strateg/childnutirtion/index.htm

[onlineApril2007]9. www.betterhealthchannel.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Iron_explained?open

[onlineApril2007]10. www.chw.edu.au/parents/factsheets/iron.htm


7.10 Lactose intoleranceLactoseintoleranceisaconditionwhichresultsinaninabilitytodigestlactose.Lactoseisasugarfoundinmilk.Lactosemustbebrokendowninthebodyinthesmallintestinebyanenzymecalledlactase,intoitsindividualcomponents-glucoseandgalactose-beforeitcanbeabsorbed.Aninabilitytodigestlactoseduetoadecreasedorabsentlactaseactivitycanresultinsymptomsof:

diarrhoea■■

nausea■■

flatulence■■

abdominaldiscomfortanddistensionaftertheingestionoflactose■■

Dietarylactoseeliminationorclinicaltestsareavailabletodetectlactoseintoleranceanditisimportanttohavethiscorrectlydiagnosedbyadoctor.Thesetestscanincludenon-invasivehydrogenbreathtesting,stoolaciditytestorinvasiveintestinalbiopsydeterminationoflactaseconcentrations(1).

Lactoseintoleranceisadistinctentityfromcow’smilksensitivity,whichinvolvestheimmunesystemandcausesvaryingdegreesofinjurytotheintestinalsurface.Cow’smilkproteinintoleranceisreportedin2%-5%ofinfantswithinthefirst1to3monthsoflife,typicallyresolvesby1yearofage(1).

Frequentrunnystoolsdonotmeanabreastfedinfanthasdiarrhoeaorlactoseintolerance:theyaresimplyviewedadevidenceofsufficientmilk.Diarrhoeaentailsveryfrequentwaterystools(2).

Causes of lactose intolerance Congenital alactasia or hypolactasia

Thisconditionisseenininfantsfrombirthandresultsintheenzymelactaseeitherbeingabsentorpresentinlowlevels.Thisconditionisrare.

Primary lactose intolerance

Thisconditionresultsinanabsentorlowlactaseactivity.Itisrarebeforetheageof3years.DecreasedlactaseactivityisgeneticallyinheritedandismorecommonamongstnearEastandMediterranean,Asian,AfricanandNorthandSouthAmericanethnicgroups.Thisconditiongenerallypersiststhroughoutlifeandrequireslife-longadherencetoalowlactosediet,atalevelofrestrictionthateliminatessymptoms.

Secondary lactose intolerance

Thisisusuallyonlytemporaryandoccursasaresultofdamagetotheintestinalmucosa,forexample,coeliacdisease,inflammatoryboweldiseaseorgutsurgery.Itmayalsooccuraftergastroenteritis.Treatmentrequiresalowlactosediettobefollowedforashortperiodoftime.

Developmental lactase deficiency

Relativelactasedeficiencyobservedamongpreterminfantsoflessthan34weeksofgestation.


ManagementBreastfed Infants

Lactoseisthesugarinallmammalianmilks,itisproducedinthebreastandisindependentofthemother’sconsumptionoflactose(3).Breastmilkcontainsaround7%lactose.

Itisuncommonforbreastfedinfantstoexhibitsignsofprimaryorsecondarylactoseintolerance.Breastmilkisusuallywelltolerateddespiteitcontaininglactose.Breastfedinfantsshouldbecontinuedonhumanmilkinallcases.

Ensuringtheinfant’scorrectattachmenttothebreastinordertoalloweffectivedrainageisimportant.Encouragingtheinfanttofinishsucklingonebreastbeforeofferingthesecondmayalsobehelpfulforinfantssufferingfromlactoseintolerance.Thisresultsintheinfantreceivingahigherfatfeedandtendstodelaygastricemptying.Italsoslowstherateatwhichlactoseispresentedtothesmallintestine.

Althoughlactosefreecow’smilkproteinbasedformulasarereadilyavailablenostudieshavedocumentedthattheseformulashaveanyclinicalimpactoninfantoutcomesmeasureincludingcolic,growthordevelopment(4).

Lactasedropsareanoptioninexpressedbreastmilk–butthesearenotalwayshelpful.

Inspecialcasesbreastfedinfantsmayberequiredtochangetoalowlactoseformula.Breastfeedingshouldonlybeceasedduetolactoseintoleranceafterreceivingmedicaladvice.

Formula fed Infants

Indevelopedcountriesenoughlactosedigestionandabsorptionarepreservedsothatlow-lactoseandlactosefreeformulashavenoclinicaladvantagescomparedwithstandardlactosecontainingformulas.Infantswithsecondarylactoseintoleranceshouldonlybegivenlactosefreeformulasforashortperiodoftimeasprescribedbyadoctor.

Note Althoughsoymilkformulaearelowinlactose,theyarenotthefeedofchoiceforthetreatmentoflactoseintolerance.Forinfants,acow’smilkbasedlowlactoseformulashouldberecommended.

Low lactose solids

Itisrareforyoungchildrenlessthan3yearsofagetohaveprimarylactoseintolerance.Lactoseintoleranceinthisagegroupusuallyexistsduetoaninjurytotheintestinalmucosa.Lowlactosedietsshouldusuallyonlyberequiredforshortperiodsoftime.

Forchildrenrequiringlongtermadherencetoalowlactosediet,advicefromadietitianshouldbesought.Itisimportantthatmealsremainbalancedandthatnutrientrequirementssuchascalciumaremet.Amoreextensivelistoflowlactosefoodscanthenbeprovided.

Childrenvaryintheleveloflactosetheycantolerateanditisoftennotnecessarytoeliminatealldairyfoodsfromthediet.Oftenlevelsoflactoseequivalenttotheamountin1glassofmilkaretoleratedeachday.Somemilkproductssuchasyoghurt,buttermilkandhardcheeses(eg.swiss,cheddar)containonlysmallamountsoflactoseandareusuallywelltolerated.

Itisimportanttotestachild’sleveloftoleranceandprovidethemaximumamountofdairyfoodpossibletoensureadequatecalciumintakes.Acalciumsupplementmayberequiredifintakesoflowlactosemilkorcalciumfortifiedsoymilkarelow.

Forsecondarylactoseintolerance,lowlactosefoodsandfluidsshouldbeprovidedfor1-4weeksdependingontheseverityofthesymptoms.Anormaldietshouldthenbegraduallyintroduced.


Table 26 Lactosecontentofcommonfoods

Food Lactose content (g)Regular milk, 200 ml 9.4Cheese, 35g slice(Edam,Swiss,Brie,Cheddar) 0.0Processed cheddar, fetta 0.1Cottage cheese, 100g 1.4Cream cheese 3.2Ice cream, 50g 2.8Yoghurt, 200g* 7.8

*Thelactosecontentinyoghurtdecreaseseachday,evenwhileitsitsinthefridge,becauseitsnaturalbacteriauselactoseforenergy.

Hidden sources of lactose

Breads, biscuits, cakes and other baked goods■■

Processed breakfast cereals■■

Mixes for pancakes, biscuits and cookies■■

Margarine■■

Cheese studies, cream soups■■

Custard■■

Milk chocolate■■

Salad dressings■■

Dairyfoodsareanimportantsourceofcalcium.Ifthesefoodsareeliminatedfromthedietitisessentialtoreplacethemwithothercalciumrichfoodsegcalciumfortifiedsoyproducts.

Useful websiteswww.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Lactose_intolerance?open

www.breastfeeding.asn.au/bfinfo/lactose.html

www.lactose.com.au/

www.mayoclinic.com/health/lactose-intolerance/DS00530

www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=1787

www.chw.edu.au/parents/factsheets/pdf/low_lactose_diet.pdf

ReferencesHeymanM2006LactoseIntoleranceinInfants,ChildrenandAdolescentsPaediatrics1181.(3)1279-86.

DietaryGuidelinesforChildrenandAdolescentsinAustraliaincorporatingtheInfant2.FeedingGuidelinesforHealthWorkers,NHMRC,Canberra2003.

3.AndersonJ(2006)Lactoseintoleranceandthebreastfedbaby.Essencemagazine3.35(1).

HeubiJetal(2000)Randomisedmulticentertrialdocumentingtheefficacyandsafetyofa4.lactosefreeandlactosecontainingformulaforterminfantsJAmDietAssoc100;212-217

TheGUTFoundation:[online:May2007]5. www.gut.nsw.edu.au/free3.htm


7.11 Regurgitation and gastro-oesophageal refluxThepassageofgastriccontentsintotheoesophagusisanormalphysiologicalprocessthatoccursinhealthyinfantsandchildren.Infact,inhealthyinfants,gastricfluidsmayfrequentlyeruptintotheoesophagus,anywherefrom10to50timesaday(1).Many,butnotalloftheseepisodesresultinregurgitation.Regurgitationdescribesrefluxintotheoropharynx.Regurgitationismostfrequentlyreportedbetween1and3months(50%)toaround4months(61%).Bythetimetheinfantis10to12monthsold,only5%ofparentsstillreportitasaproblem(1).

Gastro-oesophagealreflux(GOR)isaconditionoffrequentregurgitationorvomiting,oftenbeginningbetween2and6weeksofage(2).

Thesymptomsinyounginfantsdifferfromthoseseeninolderchildrenandinclude:

excessivecrying■■

irritability■■

backarching■■

breastrefusal■■

feedingdifficulties(1,2)■■

Mostinfantswithregurgitationorrefluxremainhealthyandthrive,andthesymptomssettledownbetween6and10monthsofage,whentheinfantbeginstospendmoreofthedayinanuprightposture(2).Ifsevere,itcanleadtogastro-oesophageal reflux disease (GORD),whenrefluxleadstopathologicalconsequencessuchas,oesophagitis(inflammationoftheoesophagus)failuretothrive,recurrentaspiration(whichmaybeassociatedwithapnoea)andpneumonia.

Gastro-oesophageal reflux is significantly less common in breastfed infants than in those fed formula. This finding is unrelated to feed volume (2).

DiagnosisThediagnosisofgastro-oesophagealrefluxismadeonclinicalgrounds.Itisimportanttodetermineifsymptomsarecausedbyanunderlyingpathologicalcondition,orifthereisevidencerefluxiscausingsecondarycomplicationssuchasfailuretothrive.

Inmostcasesrefluxisuncomplicatedandlittleinterventionisrequired.

Investigationisrequiredonlywhencomplicationsarepresentoriftheinfantdoesnotrespondtosimplemanagementmeasures(2).

Some warning signs of underlying pathology (1)

Doestheinfanthave:

Biliousand/forcefulvomiting■■

Onsetofvomitingafter6months*■■

GIbleeding*■■

Constipation■■

Diarrhoea■■

Abdominaltenderness,distension■■

Fever■■

Lethargy■■

Failuretothrive*■■

*mayalsobeasymptomofGORD

Refer for medical intervention if the infant has one or more of these symptoms


Reflux and poor weight gainInfantswithrecurrentvomitingandpoorweightgainshouldundergoevaluationfortheadequacyofcaloricintakeandtheeffectivenessofswallowing.

PoorweightgaindespiteanadequateintakeofcaloriesshouldpromptevaluationforcausesofvomitingandweightlossotherthanGORD.

Referral to dietitian

ManagementReassurance

Themajorityofinfantswillhavephysiologicalregurgitationandwillsettlespontaneously.Providedtheinfantisthriving,noinvestigationorinterventionisrequired.Itisimportantnottolabelthesechildrenashavingaconditionsuchasgastro-oesophagealreflux(2).

Posture (2)

Placingtheinfantinamoreuprightfeedingpositioncanbehelpfulforregurgitation.■■

Keepingtheinfantuprightfor15to30minutesafterfeedingalsohelps;ababyslingis■■

usefulinthissetting.

Thebestpositionforreducingrefluxispronebut,becausethispositionhasbeen■■

associatedwithanincreasedincidenceofsuddeninfantdeathsyndrome,itisnotgenerallyrecommended.

Nootherlyingpositionhasbeenshowntobeeffective.■■

Food thickening

Whenbreastfeeding,liquid■■ Gavisconissometimeseffective,althoughitcancauseconstipation(2).

Recentlyinfantformulascontainingathickeningagent(ARformulas)havebecome■■

widelyavailable…..Theyshouldbeconsideredonlyforreducingregurgitation;theyarenotananti-refluxformula(2).

Thickeningsolidfeedswithricecerealcanassistinregurgitation.■■

If an infant is placed on a thickened feed or is using a thickener, this should only occur under appropriate medical supervision.


Milk free diet

Somestudiesreportupto40%ofinfantswithGORhasacow’smilkproteinintolerance.Thisisimportanttoinvestigate,particularlyiftheinfanthaspoorweightgain,irritabilityandfeedingrefusal(3).

Referral to dietitian for assessment and advice

Drug therapy

Drug therapy should be given only under medical supervision.

Therearetwopossibletherapies:acidreductionanduseofprokineticagents.Atpresentthereisnodrugavailablethatistrulyanti-reflux(2).Inmostcasestheyarenotvaluabletreatmentofinfantswithregurgitation(1).

Outcome

Active medical management controls symptoms leading to:

50 % of children needing no further therapy beyond 8 to 10 months of age■■

30 % beyond 18 months of age. ■■

However, 17% of patients have ongoing symptoms or complications requiring anti-reflux surgery (2)

Surgical intervention

Surgicalinterventionisrestrictedtoinfantsforwhommedicalmanagementhasfailedand/orwhohavepotentiallylife-threateningcomplicationssuchasapnoeaoraspiration.Thisisrare.

ReferencesWinterH.S.(2007)GastroesophagealrefluxinInfants,1. www.uptodate.com/udt/content/topic.do?topicKey=pedigast/16818[online]18thApril,2007

DietaryGuidelinesforChildrenandAdolescentsinAustraliaincorporatingtheInfant2.FeedingGuidelinesforHealthWorkers,NHMRC,Canberra2003.

SalvatoreS.,VandenplasY.,(2002)Gastroesophagealrefluxandcow’smilkallergy:Is3.therealink?PedatricsNov2002.110(5):972

HuangR-C.,ForbesDA.,DaviesMW.,(2003)Feedthickenerfornewborninfantswith4.gastroesophagealreflux.CochraneReviewAbstracts