Infants, toddlers and school children need to satisfy their energy and nutrient requirements for normal growth, development and activity through eating a varied and balanced diet. The UK Department of Health’s Dietary Reference Values  and the Scientific Advisory Committee on Nutrition’s (SACN) energy recommendations  can be used as a guideline for the healthy child (Tables 1.9–1.11). In addition the Food Standards Agency has set maximum guideline daily amounts of sodium and salt consumption for babies and children  in order to tackle the longer term problems of hypertension and cardiovascular disease found in the adult population (Table 26.1). However, these are not evidence based for children and at only 50% above the reference nutrient intake (RNI) for sodium they are difficult to achieve in practice, despite a reduction of approximately 15% of the salt content in some commercial foods over the last few years.
Table 26.1 Guideline daily amounts of sodium and salt
|Reference nutrient intake ||Daily recommended maximum intake |
|Age||Sodium g/day||Sodium g/day||Salt g/day|
UK Government policies emphasise healthy eating for children through a number of initiatives:
- promoting breast feeding
- broadening the nutritional support given to low income families through the Sure Start and Healthy Start schemes
- Healthy Child Programmes [4, 5]
- widening children’s exposure to fruit and vegetables through the School Fruit and Vegetable Scheme
- voluntary guidelines on food to be served to children in Early Years settings
- nutritional standards for school meals and food available in state schools including vending machines and tuck shops
- promoting initiatives to combat obesity 
Breast milk and infant formula are the only two options of milk drink throughout the first 6 months of life. Both are nutritionally adequate but breast milk is the preferred option as it additionally provides protection against illness .
Colostrum is the breast milk produced in the first few days after birth and is particularly high in proteins, especially immunoglobulins, which confer maternal immunity against infection. It is low in fat and energy and newborn babies generally take very small volumes infrequently . Over the first few days infants have a net weight loss, which is mostly fluid, of up to 10% of their birthweight. From about days 2–3 postpartum the composition of breast milk changes to transitional milk which has a higher water content and coincides with the infant demanding feeds more frequently. Mature breast milk is produced about 3 weeks postpartum.
The average energy composition of mature breast milk has been estimated to be 69 kcal (289 kJ)/100 mL . A recent systematic review of data from 1088 samples of mature breast milk showed an energy content of 65.2 ± 1.1 kcal/100 mL (273 ± 4.6 kJ)/100 mL . The energy content varies throughout the feed: at the beginning of the feed the milk is low in fat and higher in lactose and satisfies the infant’s thirst; as the feed progresses the fat and energy content increases and the high fat milk towards the end of a feed satisfies the infant’s hunger.
Mothers should be encouraged to let their infant drink as much as desired from the first breast before offering the second breast; this way the infant gets the higher energy milk at the end of the feed. Less milk (or none at all) may be taken from the second breast offered. At each feed the first breast offered should be alternated so that both breasts receive equal stimulation and drainage. Young infants may need to be woken by cuddling them upright and changing their nappy after finishing at the first breast before being offered the second breast.
Provided there is no restriction on how much an infant can breast feed (i.e. demand feeding is practised) no extra water is needed, even in very hot weather, as the infant will simply feed more frequently to obtain more fluid when thirsty.
Breast feeding offers the infant several advantages over formula feeding [7, 11–13]:
- optimal growth and development
- reduced incidence of gastrointestinal, urinary tract and respiratory infections
- reduced risk of otitis media until the age of 5–7 years
- reduced incidence of both insulin and non insulin dependent diabetes
- growth factors, which enhance the infant’s gut development and maturation
- reduced risk of constipation
- reduced incidence of some childhood cancers (leukaemia and lymphomas, e.g. Hodgkin’s disease)
- reduced risk of sudden infant death syndrome (SIDS)
- fewer visits to the doctor in the first 2 years of life
Evidence is controversial around whether breast feeding reduces
- risk of childhood obesity [14, 15]
- severity of the allergic conditions asthma and eczema [16, 17]
Benefits of breast feeding for the mother include [12, 16]
- delay in return to menstruation allowing maternal iron stores to replenish following pregnancy and childbirth
- reduced risk of breast and ovarian cancer 
- helps the return to pre pregnant weight
- lower risk of postnatal depression
- women over the age of 65 years who have breast fed show a lower incidence of osteoporosis and hip fractures
There are some contraindications to breast feeding:
- the baby has classical galactosaemia, a long chain fatty acid oxidation defect or glucose-galactose malabsorption
- the mother is taking certain medications, receiving radiotherapy or chemotherapy, is a drug abuser or takes excessive alcohol
- HIV positive status of the mother as HIV transmission from mother to infant can occur via breast milk; however, in developing countries, where formula feeding may greatly increase the risk of gastrointestinal infections and mortality, breast feeding is preferable
Health professionals can support and promote breast feeding through policy development, through the provision of environments conducive to breast feeding and by having the knowledge and skills to give consistent practical advice and support to breast feeding mothers.
Factors which improve rates of breast feeding include the following.
- The UNICEF Baby Friendly status of the maternity unit where the baby is born. The UNICEF UK Baby Friendly Initiative provides a framework for the implementation of best infant feeding practice in maternity units and is represented by the Ten Steps to Successful Breastfeeding (Table 26.2). Accredited units which have successfully implemented all 10 steps have increased breast feeding rates.
- Early contact between mother and baby. Healthy infants should be placed and remain in direct skin-to-skin contact with mother immediately after delivery until the first feeding is accomplished . Putting the baby to the breast immediately after birth assists in developing the suckling reflex which is particularly strong for a short while after delivery.
- Extra support by trained professionals with special skills in breast feeding to help with good positioning and technique . A good understanding of the physiology of lactation is essential for all who are involved in the care of breast feeding mothers and can be achieved with training. The UNICEF Baby Friendly Initiative has developed an accreditation system for assessing higher education institutions in the UK based on the training they provide to midwives and health visitors on breast feeding.
- Peer support. Local peer support groups are particularly effective . In the UK, the large nationally organised groups which provide peer support and training for counsellors are
- Association of Breastfeeding Mothers
- Breastfeeding Network
- La Leche League
- Multiple Births Foundation
- National Childbirth Trust
- Association of Breastfeeding Mothers
- Family support and encouragement.
- Supportive communities where breast feeding is seen as the norm and facilities are available for women to breast feed. Both England and Scotland have legislated against discrimination towards mothers feeding infants in public places. The UNICEF Baby Friendly Initiative also accredits community settings if they are implementing the Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings.
Table 26.2 The 10 steps to successful breast feeding 
Perceived barriers to breast feeding may include
- Too much demand on the mother’s time. Family members can provide invaluable support by helping with other children or taking over household duties.
- Embarrassment. Some mothers are embarrassed to breast feed even within the home, particularly those in lower socioeconomic groups . Many women find that the attitude of other people to breast feeding in public, coupled with the frequent lack of facilities to feed in private, make prolonged excursions outside the home difficult.
- Jealousy and lack of support from other family members. Husbands, relatives and siblings may resent the exclusive role of the mother in breast feeding. Involving everyone in all other aspects of caring for the infant can help alleviate this problem.
- Incompatibility with work. Women in the UK are entitled to 12 months maternity leave (9 months of this paid). However, many return to work within 12 months and unless there are suitable facilities for child care or expressing breast milk, continuing with full breast feeding can be difficult. Partial breast feeding (e.g. in the mornings and evenings) is often possible on return to work and should be encouraged.
Initiating, establishing and maintaining breast feeding
Breast feeding is not an entirely instinctive process and most new mothers need support and advice. The 2010 Infant Feeding Survey (Table 26.3) reported that 81% of UK mothers initiate breast feeding soon after birth; however, exclusive breast feeding declines rapidly with only 46% mothers doing so at the end of the first week, 23% at 6 weeks and 1% at 6 months . This decline is often due to lack of support to address common problems and difficulties. The National Institute for Health and Care Excellence (NICE) recommends that when mothers leave a maternity unit they should be given contact details of breast feeding counsellors and information on local peer support groups .
Table 26.3 Incidence and prevalence of breast feeding in the UK
|% of infants in the UK receiving some breast milk||% of infants in the UK being exclusively breast fed|
|Age of infants||1995||2000||2005||2010||2005||2010|
Good positioning and attachment is essential for successful breast feeding. Infants should be held so that
- they are close and facing the mother with their tummy towards her
- the baby’s back, shoulders and neck are supported
- they can easily tilt their head back
- their head should be in line with the body so that the neck is not twisted
The baby’s mouth will gape wide open in response to the rooting reflex to accept the nipple and it is important that the baby takes in the nipple and much of the areola. The lower lip should be turned out and the tongue under the mother’s nipple.
During the first few days infants take minimal amounts of colostrum (21.5 ± 4.2 mL on day 1 ) and its provision is under hormonal control (Table 1.15). After day 3 postpartum the supply of transitional, and later mature, breast milk is determined largely by demand and is stimulated by regular, rather than prolonged, suckling. During the early weeks of demand breast feeding mothers may need to feed every 2–3 hours or 8–12 times a day. Once lactation has become fully established after about 3–4 weeks, the time between feeds usually increases although some infants continue to prefer smaller more frequent feeds.
If the baby is unable to suckle at birth, the mother can express her milk. Expressing 8–12 times a day will be necessary to establish a good milk supply and considerable practical and emotional support is important for these mothers.
Complementary and top-up feeds
Complementary formula feeds usually hinder breast feeding by decreasing the demand and hence supply of breast milk. Very occasionally when an infant is not gaining sufficient weight, a complementary feed after the breast feed may be recommended.
Problems and difficulties with breast feeding
Some problems and difficulties with breast feeding are shown in Table 26.4.
Table 26.4 Common breast feeding problems and suggestions for their management
|Perceived inadequate supply|
A common reason cited by mothers and may be due to persistent crying or fussing of infants that are not necessarily signs of hunger
|Crying in a baby does not always signal a demand for food. It may be because the baby is uncomfortable, needs a nappy change, is overtired, or just bored and lonely|
A breast fed baby having an adequate intake will
|Check the baby is feeding for as long as s/he wishes on both breasts. More frequent breast feeds may help establish a better supply or suit a mother who produces low volumes of breast milk. Check mother’s diet and fluid intake are adequate and that she is getting enough rest|
|Sore nipples||Some tenderness is normal but breast feeding should not be painful. Pain is usually due to poor attachment and positioning. However, in some cases it may be due to thrush (Candida albicans). In rare cases it may be due to Reynaud’s syndrome, where nipples become blanched due to poor blood supply||Treatment from a GP is necessary to resolve thrush in both the mother and infant|
Heat treatment and feeding in a warm room may help in Reynaud’s syndrome
|Cracked nipples||Usually due to poor attachment||With improved attachment and positioning nipples will begin to heal|
Oedema caused when the breast is full of milk and the blood and lymph flows are slow and seep into breast tissue
|Usually due to poor drainage of the breast as a consequence of poor positioning and attachment and can occur when feeds are missed||Hand expressing before the feed can make it easier for the infant to suck efficiently. Advice may include|
Swollen, inflamed or infected area in breast
|Usually a result of engorgement or poor drainage of the breast so it is important not to stop breast feeding||Advise rest, frequent breast feeds and that the mother should drink plenty of fluids. Antibiotics may be needed|
|Baby has poor weight gain||Less emphasis is now placed on frequently weighing healthy infants as small variations in weight centiles can cause considerable parental stress. Weight gain is not expected to be regular:||Check the weight chart carefully and reassure the mother if possible. Check position and feeding technique. Check the number of feeds being offered and if necessary advise an increase to 2 hourly feeds during the day. If top-up formula feeding is necessary, advise the mother to give the bottle at the end of each breast feed to encourage stimulation of breast milk with the goal of fully resuming breast feeding|
Refer to the GP for assessment if growth is faltering
|Tongue tie||If severe can limit the infant’s ability to suckle effectively||Refer for an assessment. Surgery resolves the problem.|
Expressing breast milk
Once breast milk supply is established it can be expressed using one of three methods:
- by hand
- using a hand pump
- using an electric pump
NICE recommends that all mothers are taught to hand express their milk . Expressed breast milk (EBM) can be given to the baby via a spoon, cup or a bottle, although not all babies are happy to accept an occasional feed in this way. Bottles, containers for storage and other utensils must be sterilised until the infant is 1 year of age. EBM should be labelled and stored correctly to minimise the risk of infection. The Department of Health recommends that EBM is stored:
- in the refrigerator for up to 5 days if parents are confident that the fridge remains at 4°C or lower. It should be stored at the back of the fridge where it is colder. A domestic fridge that is opened frequently may not maintain a low enough temperature; it is preferable to freeze EBM if it is not going to be used within 48 hours
- in the freezer compartment of a fridge for up to 2 weeks
- in a domestic freezer at −18°C for up to 6 months
Frozen EBM should be thawed in a fridge and then used within 24 hours. It must not be reheated in a microwave oven because of the risk of ‘hot spots’ occurring and causing burns . Standing the bottle in warm water is a suitable way of reheating milk if necessary; some babies will drink it cold from the fridge.
Nutrition for lactating mothers
The nutritional quality of breast milk is only affected if the mother is undernourished. To support lactation higher requirements for energy, thiamin, riboflavin, niacin, vitamin B12, folate, vitamins C, A and D, calcium, phosphorus, magnesium, zinc, copper and selenium are set . The increased energy requirement is usually met through utilising the adipose stores deposited during pregnancy. Eating a balance of the five food groups (Table 26.5) will meet the increased nutrient requirements with the exception of vitamin D, where a daily supplement of 10 µg is recommended .
Table 26.5 Recommended intakes from the five food groups for lactating mothers
|Food group||Recommended daily intake|
|Bread, rice, potatoes and pasta and other starchy foods||Base each meal and some snacks on these foods. Use wholegrain varieties as often as possible|
|Fruit and vegetables||Include one or more of these at each meal and aim for at least five portions per day|
|Milk, cheese and yoghurt||2–3 portions of milk, cheese, yoghurt. Use low fat varieties if weight needs to be managed|
|Meat, fish, eggs, beans and nuts||2–3 portions. Two servings of fish per week are recommended, one of which should be oily fish|
|Foods and drinks high in fat and/or sugar||Limit these to small quantities and not to be eaten in place of the other four food groups. For those trying to lose weight limit them to 2 small portions per day|
|Fluid intake||To satisfy thirst but at least 6–8 drinks per day (1½–2 litres). This includes all drinks: water, tea, coffee, milk, soup, fruit juices, squashes and fizzy drinks. More drinks may be needed in hot weather and after physical activity|
Vegan mothers need to plan their diets carefully and may need additional supplements of calcium and vitamin B12.
Foods to be limited or avoided
To ensure a good intake of omega-3 long chain polyunsaturated fats (LCP), mothers should be encouraged to include fish in the diet, but oily fish should be limited to no more than two servings per week; marlin, swordfish, shark and tuna should be avoided .
Alcohol and caffeine both readily pass into breast milk and high intakes of either should be avoided during lactation. The highest level of alcohol in milk will occur between 30 and 90 minutes after ingesting alcohol; mothers should not ingest alcohol for about 2 hours before breast feeding and should keep alcohol intake to a minimum, e.g. 1–2 units once or twice per week. Regular or binge drinking should be avoided. Caffeine in tea, coffee, chocolate and energy drinks does not need to be avoided, but some mothers find large amounts of caffeine unsettle their baby.
Breast milk is believed to be flavoured by foods eaten by the mother. There are reports that highly spiced or strong tasting foods can unsettle the infant.
Infants may be sensitised to antigens in breast milk, e.g. cow’s milk protein, eggs or nuts (p. 322). If the infant reacts to the presence of these antigens in breast milk, the mother needs to avoid these foods. If dairy products are avoided she will need advice on dietary adequacy which may need to include a calcium supplement.
Until 12 months of age the only nutritionally adequate alternatives to breast milk are infant formula from birth, and from 6 months either infant formula or follow-on milk. The composition of these two types of feed must comply with government regulations according to European Union (EU) Directives. These Directives are based on expert advice from the EC Scientific Committee for Food and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and also implement the 1981 World Health Organization International Code of Marketing of Breastmilk Substitutes as appropriate to the EU .
Recent research suggests that infant formulas may contain too high an energy level for normal growth. The energy content of breast milk may be lower than current accepted estimations and the higher energy density of infant formulas may account for the different growth patterns seen between breast fed and formula fed infants (Table 26.6) [10, 29].
Table 26.6 Energy densities of breast milk
|per 100 g/100 mL||Hester et al. 2012 ||Hosoi et al. 2005 ||McCance and Widdowson 1991 |
|Colostrum||53.6 kcal (224 kJ)||57 kcal (238 kJ)||56 kcal (236 kJ)|
|Transitional milk||57.7 kcal (241 kJ)||63 kcal (263 kJ||67 kcal (281 kJ|
|Mature breast milk||65.2 kcal (273 kJ)||64 kcal (268 kJ)||69 kcal (289 kJ)|
Table 1.14 lists the infant formulas available in the UK. The whey dominant formulas (whey:casein ratio of 60:40) have a protein ratio that is similar to that found in mature breast milk; those with a lower whey:casein ratio (20:80) are more similar to the protein ratio found in cow’s milk. The energy and nutrient contents are similar in both types of feed, although the casein dominant formulas are marketed as more suitable for hungry babies; this is simply because the curd formed by the higher casein level slows gastric emptying.
Formula fed babies should be demand fed just as breast fed babies are and offered adequate feed to satisfy their hunger and growth needs. This will approximate to a total daily intake of around 150 mL/kg body weight/day, although it varies with each baby. The number of feeds per day and the volume taken at each feed will vary as in breast feeding.
These milks (Table 1.14) are only recommended from 6 months of age as they have higher levels of protein, minerals and some vitamins than the infant formulas designed for feeding from birth. Some mothers choose to use them but it is not generally necessary. They can be used to give additional nutrients to children who do not eat solids very well and they have been shown to reduce iron deficiency anaemia in inner city deprived populations [30–34].
Making up infant formula from powder
Tap water or bottled waters which comply with EU standards for tap water  may be used for making up infant formula. Up to 200 mg/L sodium is allowed in tap water which will add 0.9 mmol sodium/100 mL feed. This extra sodium will not matter for most infants and powdered feeds on sale in the UK will still comply with the EU Directive’s acceptable sodium content if made up with water containing this level of sodium. Bottled mineral waters may contain excess amounts of sodium or other electrolytes and should not be used for making up infant formula. Just as tap water must be boiled before being used for reconstituting formula feeds, so must any bottled water. Carbonated fizzy water is not suitable for making up formula feeds.
Infant formula powder is not sterile and may contain microorganisms such as salmonella and Enterobacter sakazakii (now known as Cronobacter sakazakii). Neonates, particularly those who are preterm, of low birthweight or immunocompromised, are most at risk. To minimise the risk of gastroenteritis from these bacteria:
- feeds should be made up using boiled water >70°C (that has been left to cool in the kettle for no more than half an hour)
- this water is measured into a sterile bottle and the appropriate number of scoops of powder added (1 level unpacked scoop of powder per 30 mL/1 fluid ounce water)
- the bottle should then be sealed with a sterilised cap and shaken to mix the powder
- the feed must be cooled (by holding the sealed bottle under cold running water) and the temperature tested before giving to the baby
- bottles should be made up freshly for each feed
- any left over milk at the end of the feed should be thrown away
- parents who require a feed for later are advised to keep water they have just boiled in a sealed flask and make up fresh formula milk when needed 
If parents choose not to follow this advice and make up feeds for up to 24 hours in advance, the bottles of formula should be cooled quickly and stored in a fridge at <5°C. These feeds can be warmed just before use by standing the bottle in a container of hot water. Microwave ovens must not be used as the milk is not uniformly heated and hot spots in the milk could burn the baby’s mouth .
Feeds should be made up using boiled water and sterile bottles or cups until 1 year of age because of the potential for bacterial growth. This is enhanced if bottles, teats and cups are not cleaned properly.
In the case where a baby is prescribed a multi-ingredient feed the dietitian may deem it safer, from the point of view of accuracy of feed reconstitution, for the parent to make up 24 hours’ worth of feeds at one time. It is incumbent on the dietitian to give advice about scrupulous hygiene, rapid cooling and safe storage at <5°C if feeds are to be made up in advance. Any remaining milk not completed after 1 hour of feeding should be discarded.
Bottle fed babies should be held in a supportive, semi-upright position, which encourages eye contact and bonding with the caregiver. The bottle should be angled so that the teat is always full of milk thus minimising the amount of air consumed. It is usual to ‘wind’ bottle fed babies half way through and after a feed.
Various types of bottles are available, some with air release devices to reduce colic. Different teats have varying flow rates according to the size and number of holes and they also vary in size and shape.
Problems preparing feeds
Lucas et al.  measured the energy content of infant formulas made up by a group of bottle feeding mothers and found the energy content ranged from 41 to 91 kcal (171 to 380 kJ)/100 mL whereas the manufacturer’s intended energy content was 68 kcal (284 kJ)/100 mL. One-third of feeds contained less than 50 kcal (210 kJ)/100 mL and around half the feeds over 80 kcal (335 kJ)/l00 mL. These discrepancies may arise from
- compression of the powder in the scoop or by using heaped scoops
- miscounting the number of scoops
- adding an extra scoop mistakenly thinking it will be more satisfying for the baby
Overconcentration of the feed may lead to hypernatraemia with consequent dehydration and possible severe brain damage or death, or to hypercalcaemia and hyperphosphataemia. Much of this potential danger has been reduced following compositional changes to modern infant formulas and the redesign of packaging to improve standards of hygiene and accuracy of mixing. The use of ready to feed (RTF) liquid formulas ensures the correct concentration is always given.
Overdilution of feeds may lead to excessive volumes being ingested in order to meet energy needs and this can cause vomiting and hyponatraemia. Faltering growth and malnutrition may ensue because the capacity of the young infant’s stomach cannot cope with the much larger volumes of feed required to meet nutritional requirements.
Formula fed infants may become thirsty between feeds in very hot weather and additional drinks of cooled boiled water can be given so long as these do not interfere with the required intake of formula. Fruit juices are not necessary as formula milks contain adequate vitamin C.
Infants with fever, diarrhoea or vomiting can dehydrate quickly and need additional fluids, and possibly electrolytes, to replace losses.
When to start
The age of introduction of solid foods has become a controversial area. In 1994 the UK Department of Health (DH) recommended that weaning should begin between 4 and 6 months . In 2001 the World Health Organization (WHO) recommended exclusive breast feeding until 6 months (26 weeks) of age because of the afforded protection against gastroenteritis. Because SACN advised that breast milk is nutritionally adequate for most babies until 6 months in the UK , the DH changed its recommendation on weaning to: exclusive breast feeding (or formula feeding) is ideal until 6 months and solids should be introduced at around 6 months; should parents choose to introduce solids earlier than this then weaning should not commence before 17 weeks (4 calendar months). Both DH and WHO have advised that these ages for the introduction of solids are population recommendations and each infant should be considered individually.
Subsequently, other publications have highlighted that there is no harm in beginning solids between 4 and 6 months of age and that some infants may be at risk of nutrient deficiencies if weaning is delayed until 6 months [40–42].
Infants should therefore be considered individually and the following developmental stages indicate readiness for solids:
- putting toys and other objects in the mouth
- chewing fists
- watching others with interest when they are eating
- seeming hungry between milk feeds or demanding feeds more often even though larger milk feeds have been offered
These developmental signs are generally seen between 4 and 6 months and from this age infants learn to accept new tastes and textures relatively quickly .