Toddler and Young Children: Food, Mood and Health Guidance

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The purpose of this guidance is to support childcare providers to enhance the care they deliver and meet the food and health needs of children aged one to five years. This guidance has been informed by discussions with child care providers and carers, a literature review and models of best practice.
Perceptions of body image start in the early years and are shaped by the environment, peers and family, the media, society, and biological predisposition. Promoting a healthy body image will promote body confidence for every child no matter what age, body shape, size and appearance (Government Equalities Office , n.d.).
Physical activity is recognised as being important for all age groups no matter what their body shape or size. It is good for both mental and physical wellbeing, illness prevention and treatment. Encouraging children to develop an active lifestyle will promote positive life experiences for young children. Parents/carers can help promote activity by making it part of the family’s daily routine. Active fun is about engaging young children in activity to promote health and wellbeing and a positive body image, self esteem and confidence in a child.
Eating well can be described as consuming a nutritious and varied diet that is affordable, accessible and culturally appropriate. Supporting children to develop a healthy approach to food considers both ‘what’ and ‘how’ food is eaten.  ‘What we eat’ is about choosing everyday foods that are nutritious and supports growth and development.  ‘How we eat’ is about connected eating – building on the innate ability to tune in to internal signals of hunger and fullness.
Healthy weight varies from person to person. An assessment of a young child’s health should not be based on their body shape and size alone. Parents/carers, childcare providers and family support practitioners are key to enabling children to maintain a healthy weight. A healthy body is one that, whatever shape, size, or weight, is in a state of wellbeing, has enough energy, strength and stamina to be active, allows a person to achieve his or her goals, and participate in life.
Early year’s services have a valuable role to play in promoting healthy eating to children, parents/carers and the wider community. The ‘Curriculum for Excellence’ includes healthy eating and physical activity topics within the ‘Health and Wellbeing Outcomes’ for the early stage.
This guidance contributes to the delivery of NHS Highland’s health and weight strategy. As such, it is underpinned by an approach called Well Now. Well Now is a weight-inclusive approach developed by dietitian Lucy Aphramor. Well Now promotes body respect, and it teaches Connected Eating which integrates people's circumstances, including trauma, in discussion around food and health.The planning for fairness process has been applied to these guidelines to ensure that they address Equality and Diversity issues.

Recommendations

Healthy Body Image - Help children to feel confident about their bodies by encouraging a well balanced diet and an active lifestyle; this can positively affect physical, mental and emotional wellbeing for children of all shapes and sizes
Fluid – What to drink – 6 to 8 drinks of 100mL to 150mL of fluids/per day, suitable fluids include water or milk.
How to drink - use an open cup where possible
Eating Well – What to Eat - A variety of everyday food based on the four food groups
How to Eat - Tune into senses of hunger and fullness and stop when full. It is advised not to force a child to eat when they are not hungry. Share meals together with your child whenever possible. The parent/carer is responsible for providing food, when the child eats and where the child eats. The child is responsible for how much they eat and whether they want to eat.
Dentist - A child should be registered with a dentist soon after birth and before their 1st birthday
Vitamins – Parents/Carers should speak to their health visitor about a suitable supplement for the age of their child.
Physical Activity - 180 minutes of activity / day should be spread through the day rather than one long session. Physical activity should be enjoyable and engaging.

Purpose

The purpose of this guidance is to support child care providers to enhance the care they deliver and meet the food and health needs of children aged one to five years. The purpose of this guidance is to help childcare providers meet the Scottish Government National Care Standards: Early Education and Childcare up to the age of sixteen (Scottish Government, Revised September 2009).
This guidance is for anyone who looks after children including childcare providers in Early Years and Childcare settings, partner centres, foster/adoption services, and also childminders, health visitors and other health, social care and educational staff. Whilst this guidance is not explicitly aimed at parents/carers they are part of the intended audience. This guidance outlines best practice on a healthy body image and eating well for children aged one to five years (both actual and developmental age) in Highland Health & Social Care Partnership. It highlights the important role child care providers have in food and health education in the early years. All who are involved in the health and wellbeing of children have a key role in ensuring that additional help and support are in place at the earliest stages (NHS Health Scotland, 2015), (Scottish Government, GIRFEC, n.d.), (Scottish Government, 2011)
This guidance is the revised and updated chapter four of The Maternal and Child Nutrition Best Practice Guidance (2012). It was informed by a Needs Assessment; it was identified that this document would be better utilised by professionals if it could be accessed as standalone guidance for Body Image and Eating Well for children aged one to five years. It is worth noting that weaning may still be taking place after a child is one year old but the scope of this guidance does not cover it.

Background
In order to update and develop this document a needs assessment about toddler nutrition has been completed which has included the following:

  • Discussions with over 150 child care providers including those in the Early Years and
    Childcare settings, partner centres, foster/adoption services, and also childminders, health
    visitors and other health, social care and educational staff.
  • Reviewing the literature – A literature search was undertaken which included:
    • the role and impact of healthy weight interventions in Early Learning and Childcare
    • preventing body dissatisfaction in children


For more information see 'Needs Assessment' section

A healthy body image

What influences body image in children?

Perceptions of body image start in the early years and are shaped by the environment, peers and family, the media, society, and biological predisposition. Promoting a healthy body image will promote body confidence for every child no matter what age, body shape, size and appearance (Government Equalities Office , n.d.).

Frequently comparing your body to others around you can make you feel second best or unattractive.

Parents/Carers can provide both the genes and environment for eating patterns and play an important role in shaping a child’s development (Savage, et al., 2007). Children often model their behaviour on others. Therefore, encouraging eating well with people who are around children is important in reinforcing the right messages.  The feelings that parents/carers communicate around body shape, appearance and dieting can have an impact on a child. There is a correlation between a mothers own disturbed body image and the disturbed body image of a young child, which could be expressed in eating behaviours and preoccupation with body image (All Parliamentary Group on Body Image , 2012).

The parent/carer is not the only source of influence; media also has a powerful role to play in shaping attitudes and behaviours of children. Having a positive body image supports a child to develop into a confident individual, which can lead them to healthy lifestyle choices like healthy eating and physical activity (Scottish Government , 2014).

Having a healthy body image is good for children (and parents/carers too), no matter what their weight, shape, size or appearance.

Why Body Image is Important

Children are born loving their bodies, curious about them, inclined to move, and driven to be physically competent as they can be.  Good parenting skills and activity preserves those qualities throughout the growing up years.

Encouraging children to feel positive about their bodies supports self confidence and is more likely to lead to healthy lifestyle behaviours. A child with a positive body image is less likely to have a range of poor health outcomes, including depressive symptoms, low self esteem, lower physical activity and greater risk of disordered eating and clinical eating disorders (Department of Health , 2011).

How to encourage a healthy body image

A well balanced diet and an active lifestyle can positivity affect physical, mental and emotional wellbeing, for children of all shapes and sizes.

Leading by Example

  • Encourage a well balanced diet based on a wide variety of foods.
  • Model the enjoyment of healthy food.
  • Eat together whenever possible
  • Children and adults often need to relearn how to tune into their body’s natural sense of hunger and fullness.
  • Provide children with opportunities to make their own choices about food, and an understanding of what might influence these choices.
  • Avoid using food as a reward (or punishment)

Promoting a Healthy Body Image

  • “Diet talk” or judgments on people’s size or shape may not be helpful
  • Health gain through better food, physical and social activity is achievable with or without a change in body size or shape.
  • Encourage children to feel confident, to be able to raise concerns, and to recognize and care about other people’s feelings.
  • Help children recognise when people are being unkind about their or other people’s size and shape, and how to respond appropriately.

Living in the wider world

  • Encourage an active lifestyle, with an emphasis on enjoyment
  • If a child has their weight measured by a health professional, and it is well above or well below the ideal healthy weight range, a conversation about what might be influencing weight can take place
  • A pursuit of weight loss (dieting) is not recommended as it is most likely to lead to weight gain in the longer term.
  • Promote critical consumer skills by both reducing exposure to the media, and increasing the awareness of the messages that media conveys about unrealistic and unachievable body size ideals.
  • Encourage children to have a healthy body weight by supporting them to eat to appetite, avoid labeling food as ‘good’ or ‘bad’, comfort children with attention, listening and hugs instead of food, and encourage regular meals. There is more on this area in 'How to encourage Healthy Body Weight' section.

Resources

Eating Well Body confidence in Children
Conversation Tool for Healthy Weight
Conversation Tool for Physical Activity
eLearning Module - https://calaelearning.co.uk/product/healthy-body-image-and-body-confidence/

Physical activity

Physical activity is recognised as being important for all age groups no matter what their body shape or size. It is good for both mental and physical wellbeing, illness prevention and treatment. Encouraging children to develop an active lifestyle will promote positive life experiences for young children.

Be a good role model

Parents/carers can help promote activity by making it part of the family’s daily routine. Active fun is about engaging young children in activity to promote health and wellbeing and a positive body image, self esteem and confidence in a child.

Physical activity should be encouraged in children because it is fun. Parents/carers should avoid suggesting physical activity is used to become thinner or more muscular.

Get involved in structuring activity

Implementing simple tasks into the daily routine of a young child will help to structure activity – like walking to the shops and playing in the park.  There are many Leisure Centres that offer a range of family based activities including parent/carer and child swimming sessions.

Physical activities are offered at

How to encourage regular physical activity

It is recommended that children are physically active for 180 minutes (3 hours) each day, and spread throughout the day rather than in one long session.  The amount of physical activity for toddlers and young children is more important than the intensity. Reducing the amount of screen time a child has, especially around bedtime, could also be beneficial.

Physical activity should be enjoyable and engaging to catch (and keep) children’s interest.

Children who are capable of walking unaided
All forms of activities are important for children, and include activities like walking, cycling, using the stairs and active play (such as skipping, running and chasing games) as well as structured physical activity (such as football, swimming or dancing).
Children under 5 are encouraged to minimise the time spent being sedentary (i.e. sitting) for extended periods (except sleeping). By reducing screen time (TV watching, computer use and playing video games) and reducing time spent in  pushchair or car seat will maximise opportunities for physical activity (Department of Health , 2011).

Infants who are not yet walking
Infants are encouraged to be physically active from birth, particularly through floor-based play and water-based activities in a safe environment.

Children with mobility issues
Physical activity for children with mobility issues should be dealt with at an individual level and will depend on the parameters of their disability.

Resources

Highland Information Trail
http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf

  • Ready Steady Toddler HIRS 1BAB/001/L
  • Play@home Toddler book (given at 12-15 months) 01463 711176
  • Book bug toddler bag (voucher posted out for family to collect from library)
  • First words hand out – 1BAB/037/L
  • Health visitors to remind carers to pick up book bug toddler bag from local library
  • Words Together handout HIRS 1CH1/003/L
  • Play@home preschool book and book bug pirate bag given out by EL@CC and library services
  • Conversation tool for Physical Activity
  • https://www.actify.org.uk/activescotland
  • https://www.bhf.org.uk/
Eating Well

Eating well can be described as consuming a nutritious and varied diet that is affordable, accessible and culturally appropriate. Supporting children to develop a healthy approach to food considers both ‘what’ and ‘how’ food is eaten.  ‘What we eat’ is about choosing everyday foods that are nutritious and supports growth and development.  ‘How we eat’ is about connected eating – building on the innate ability to tune in to internal signals of hunger and fullness.

What you eat

Diet  
Good nutrition is essential for growth and development.  Young children develop quickly and have high energy needs in comparison to their size. However the food choices we make – ‘what we eat’ – are based on more than nutritional adequacy. Choices about food, meals, snacks and drinks form part of our culture, social times, pleasure and society, and are part of young child’s life learning experience and education.

Everyday Foods
Healthy eating is based on a wide variety of different foods. Promoting a range of everyday foods for children, and increasing exposure to different tastes, textures and experiences will promote healthy choices. Everyday foods for young children should be based on the following four food groups (Scottish Government, Revised September 2009).

Four Main Food Groups

Main nutrients

Comments

Frequency

Carbohydrates

Potatoes & Grains (eg: breads, oatcakes, porridge, breakfast cereals, rice, pasta)

Fibre & energy

Wholegrain & high fibre versions promote gut health.

Daily

 

Fruit  and Vegetables

fresh, frozen, dried, juice or canned, and pulses

 

 

Vitamins, magnesium, fibre

Vitamin C aids the absorption of iron, and therefore helps prevent iron deficiency anaemia. Good fibre intakes prevent constipation.

Daily

Dairy

Milk, cheese, yoghurt and fromage frais; calcium fortified plant based milks.

Protein, calcium, Iodine, B Vitamins

Important for growth, strong bones and teeth. Excess milk intakes in young children are associated with constipation. (no more than 500mL per day)

Daily

Protein

 

Growth and repair

Daily

Fish and seafood

Protein, Iodine, Selenium, omega 3*

Twice a week. Include oily fish (salmon, mackerel, trout, herring, sardines, pilchards, and fresh tuna)

Twice a week

(unless vegetarian!)

Beans, nuts, lentils & other pulses

Protein, Fibre, Zinc, Iron, B vitamins

A good alternative or complement to meat.

Often for meat eaters (instead or alongside) & twice a day for vegetarians

Meat

Iron, Zinc, B vitamins

White or red meat. Limit red meat and processed meat like sausages, ham and bacon.

Optional

Eggs

Iron, selenium, B vitamins

Good alternative to meat.

Weekly or daily

*non-fish sources of omega 3 include: walnuts; some oils (rapeseed, canola); ground or crushed linseeds, dark green leafy vegetables, sweet potatoes and whole grains; tofu; foods that have been fortified with omega 3 e.g. fortified eggs, fish fingers.

Vegetarian and Vegan Diets

There are many cultural, ethical and environmental reasons why people may want to eat a diet that includes no products of animal origin. It is quite possible for a toddler to have such a diet and still get everything they need. However, the more any diet is restricted (for any reason), the greater the chance that the diet might be missing something important. If the diet is carefully planned, this risk is kept to a minimum. Diets based on a variety of plant based foods can be tasty and nutritious. Most nutrients can be found in adequate amounts in plant based foods. However, some important nutrients to consider are vitamin B12, omega 3 fats, the minerals: iron, calcium and iodine; and protein (see Appendix 12).

For more information on vegetarian and vegan diets, visit: www.vegsoc.org or www.vegansociety. Please be aware that these sites promote vegetarianism and veganism rather than just providing information, so try not to use them as your only source of information. The British Dietetic Association have also produced: https://www.bda.uk.com/resource/plant-based-diet.html on plant based diets.

Resources

Highland Food Plate – Everyday Eating
Vegetarian and Vegan Diets

‘Sometimes’ foods

‘Sometimes foods’ are described as those that are highly processed or contain a lot of salt, fat, or sugar, and may include take away meals, cakes, sweets and crisps. This guidance acknowledges that children will eat a wide variety of foods, and ‘sometimes’ food are part of our social and cultural world. As nutritional information can be confusing and thus poorly understood by many people, it is recommended that exposure to highly processed foods high in salt, sugar and additives are limited. Snack time provides an excellent opportunity for children to learn about everyday foods.
The ‘plate’ can be used to assess consumption of ‘everyday’ foods and suggestions of which food to increase can be offered.  This may lead to a discussion about the frequency of ‘sometimes’ foods, avoiding sugary drinks, sweets and confectionery.

 Scottish guidance is to encourage children and young people to eat a healthy varied diet and follow the national recommendations for physical activity

Salt intakes
Children under 11 years old should have less salt than adults. Because salt is added to other foods it is easy to take in too much salt. Helping children to minimize salt intake will make them less likely to develop a taste for salt when they are adults (Scientific Advisory Committee on Nutrition, 2003), (Food Standards Agency , 2016)

Sugar intakes
Small amounts to sweeten foods are fine, preferably at mealtimes. However many people in the UK have too many sugary foods and drinks. Many foods and drinks that contain added sugars can be high in calories and often have few other nutrients. High sugar diets can be a risk to dental health and there is some evidence that high sugar intakes may affect liver health. It may also increase risk of diabetes, heart disease and weight gain (The British Dietetic Association UK, 2016).

Resources

Highland Information Trail
http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf

Fluids

Children who are well hydrated reduce their risk of impaired concentration, reduced alertness and short term memory, constipation and urinary tract infections (Food Standards Scotland , 2016). 

Children should drink 6 to 8 drinks of 100-150mL of fluids/per day. 

Suitable fluids include water and milk (no more than 500mL per day of milk).  It is recommended to use an open cup where possible.

Breastfeeding 

Globally WHO / UNICEF recommends continued breastfeeding for two years and beyond, along with complimentary feeding from the age of six months (UNICEF Baby Friendly Standards, 2012), (Innocenti Declaration - Section 3, 2005), (Health and Social Care Information Centre , 2012)

  • Support Groups throughout the area
  • Facebook site: Highland Breastfeeding Support, Highland Breastfeeding Support Chat
  • Twitter Account: NHSH Breastfeed

Cows’ milk

From 12 months full fat cows’ milk is adequate as a main drink.  Infant formula, follow on formula or growing up milk are not needed (unless indicated by a registered dietitian) once the baby is 12 months old. Cows’ milk can be introduced in cooking from 6 months of age. From 2 years of age infants can go on to semi-skimmed milk if growing normally.

Growing Up milks

Experts across Europe have agreed that young children do not need fortified milks (growing up milks) to obtain particular nutrients.
Although growing up milk has higher quantities of vit A, vit D, iron and zinc, it has lower levels of iodine, calcium and riboflavin.  Per 100mL contains twice as much sugar as 100 ml of full fat cows’ milk and also some manufacturers flavor with vanilla flavouring.  The health consequence of additional sugar in a child’s diet is well documented.
Growing up milks targeting age 2 onwards have lower protein and calcium levels than semi skimmed milk.

Alternative milk

From one year of age any pasteurised whole animal milk is suitable, for example cows’, goats’, buffalos’ or sheeps’ milk. Alternatively, an unsweetened calcium-fortified soya milk, oat milk or coconut milk can be given, (First Steps Nutrition , 2015). Some non-animal “milks” may lack protein or Iodine, so dietary assessment and supervision by a registered dietitian may be needed. Cashew nut milk and almond milk are suitable if fortified with calcium. There are a range of alternatives available for people who are allergic or intolerant to cows’ milk products.
Soya protein based milks are offered from formula manufacturers as an alternative to standard soya milk – these contain greater quantities of fat and carbohydrate but contain less protein than standard soya milk.
Rice milk is never appropriate to give to a child under 5 due to concerns over the high levels of arsenic.

How to eat - Encourage children to be ‘competent eaters’

Children are born as ‘competent eaters’, with the ability to gauge their body’s need for food. They will respond to hunger and fullness and responsively feed while both breast and/or bottle feeding. Most children can regulate their own appetite, although over time they often learn to ignore these signals.
Children have small stomachs and will eat regular small amounts to meet their requirements. Helping children to tune into their appetite, and also stop eating when they are full will help develop good eating habits.

  • Toddlers may learn from the adults to eat food in response to difficult emotions – sometimes known as comfort eating. It is recommended not to use food as a comfort or reward. Instead, it is best to stick to scheduled feedings and identify whether the child is hungry or not. Emotional needs should be responded to with the appropriate action e.g. giving attention, discipline, hugs or naps (Ellen Satter, 2015).
  • Often, around two to 3 years of age, a child may refuse food during meal times or display fussy eating behaviours. Maintaining a consistent approach using the division of responsibility (below) will encourage a child to be a competent eater, and eat to appetite (Ellen Satter, n.d.).
  • Some young children are slow eaters and need to be given time and flexibility to enjoy and eat their food.

Recognising hunger and fullness and eating to appetite will help a child to develop good eating habits.

 Teaching families how to eat 

Division of Responsibility
The ‘division of responsibility’ outlines the roles of both parents/carers and children at meal and snack times in order to promote competent eating. Parents/carers will lead the child by example, acting as role models and show children how to behave at mealtimes.

Parents/Carers are responsible for:

  • what the child eats – the preparation of a selection of foods that are right for the child
  • when the child eats - provide the child with regular meals and snacks at suitable times
  • where the child eats - facilitate pleasant eating times for the child; for example a safe environment, eat with others and/or at a table, limit distractions, allow enough time.
  • Teaching the child to choose food that meets their bodies needs; this might be about having fibre for gut health, potatoes for energy, and eating sufficient to satisfy them until the next meal/snack.

Children are responsible for:

  • The amount of food eaten – of the food provided, the child decides how much food they will eat and whether they want to eat or not. If given the responsibility children have a natural ability to eat well and become competent eaters. They gauge their body’s need for food. They can eat as much as they need from the food prepared, and will grow in the way that is right for them (Ellen Satter, n.d.)
  • The range of food – of the food provided, the child can decide what to have on their plate.

The eating environment
There are many benefits attached to the eating environment and sharing meals together. When they can, parents/carers should provide an environment for eating well in a non distracting environment.
Distinct mealtimes throughout the day and ensuring children have regular meals including breakfast will help young children to develop healthy eating habits and lifelong skills for young children.
Young children should never be alone while eating, they should be encouraged to sit down, and chew food properly. Some food may need additional preparation particularly for very young children like chopping and slicing some fruits, removing stones and avoiding nuts.

Children with Learning Difficulties
This guidance acknowledges that sitting at the table might not always be realistic or appropriate for some children with Autism or Attention Deficit Hyperactivity Disorder (ADHD).
The processes carried out in the Division of Responsibility for children who have medical, temperamental and/or neurological barriers are the same as children without any of the mentioned problems. They still learn from their parents/carers and others around them. As long as parents/carers are attentive to the disorder the child might have, meal times can be done the same. Developing the skills may just take a little longer, and the child may have to work a little harder. (Ellyn Satter, 2015.)

How to promote competent eating and a healthy body weight

  • Support children to listen to hunger cues and to eat to appetite
  • Teach children to make the links between eating certain foods and how these make them feel
  • Avoid classifying foods as good or bad
  • Comfort children with attention, listening and hugs instead of food
  • Create a non distracting environment, separating eating from other activities
  • Whenever possible eat meals together
  • Ensure children have regular meals and snacks including breakfast
  • Base meals and snacks on ‘everyday’ foods
Resources

Highland Food Plate – Everyday Eating
Four food groups
Fussy Eating
eLearning Module - https://calaelearning.co.uk/product/how-we-eat/

Food, play and learning

Seeds of growth

Involving young children in the growing, purchasing, preparation and eating of a wide variety of foods will develop an understanding and enjoyment of the food choices available, enhance social skills and provide a good food education.
Children are more attached to foods that they have grown, purchased or prepared. For example, involving young children in choosing vegetables and preparing soups will help them explore and use their senses.  It supports the establishment of good eating habits for the future.

Different Cultures

Understanding where food comes from and the link between food and health are vital. Trying new textures, tastes and colours can reinforce healthy eating choices and encourage young children who have had less exposure to food choices.

Rolling Snack
A ‘Rolling Snack’ is used in some Early Learning and Childcare settings in order to give children more free flow play and the opportunity to be independent and make choices. A good Rolling Snack procedure will reflect the Division of Responsibility (see section on Teaching families how to eat) in supporting children to become competent eaters (see section on How to eat - Encourage children to be ‘competent eaters’) and make appropriate food choices based on their physical needs.

Healthy start scheme

Pregnant women and families with a child aged 4 years and under, who have a low income, may be eligible for Healthy Start vouchers. These vouchers can be used to buy fresh or frozen fruit and vegetables (as well as liquid cows’ milk and infant formula).  Recipients who have received Healthy Start vouchers in pregnancy must notify the issuing unit within 90 days of the birth of their child in order to continue to receive vouchers (NHS , n.d.). The recipients should have their National Insurance number to hand when making this call. Healthy Start Issuing Unit - 0345 607 6823

We know that not all eligible families currently receive their entitlement of ‘Healthy Start’ vouchers. Health Visitors, Early Learning and Childcare education centres are in a good position to remind parents/carers about the ‘Healthy Start’ scheme, for example display posters available from www.healthystart.nhs.uk, displays a list of local shops that accept vouchers, explore what can be bought with the vouchers and provide recipe options, as part of working with families on healthy eating topics.

From April 2017, Healthy Start vitamins are available free to all pregnant women during pregnancy from their midwife. They provide essential nutrients in the correct amounts. Ask your Midwife or Health Visitor for more information.

In addition to Healthy Start, a Best Start grant is also available to eligible families. From 12 August 2019, a Best Start foods pre-paid payment card was introduced in Scotland. Eligibility can begin from the start of pregnancy and continue until the child's 3rd birthday (or 4th birthday in some cases). More information can be found at: https://www.mygov.scot/best-start-grant-best-start-foods/ or by calling: Social Security Scotland - 0800 182 2222

A Needs Assessment was conducted with stakeholders involved in the care of children age 1 – 5 years; there was a range of areas related to healthy eating identified as challenging.  The top challenges identified are as follows:

Meeting the needs of all children

Quantity and Variety

Quantity Portion sizes vary from age to age, so it is best to be guided by the child’s appetite. A child who is a competent eater can eat the food they need in the right quantity, with an ability to tune into senses of hunger and fullness. Parents/Carers should be encouraged to support children to become competent eaters. Competent eaters have better nutrition and are more satisfied with what they weigh.  They are also healthier emotionally and socially (Ellyn Satter, 2015.) It is often useful to focus on the foods to eat more of, rather than limiting portion sizes of other foods. Specifying a portion size for a toddler does not support competent eating. Competent eating supports children who have a high BMI, who may have lost the ability to respond to internal cues of hunger and fullness, to manage their weight over time.
This relates back to the ‘Division of Responsibility’ in Teaching families how to eat section.

Variety - A child who eats a wide variety of food is more likely to meet their nutritional needs. The parent/carer is encouraged to provide a child with ‘everyday foods’ based on the four food groups (Dairy, Fruit and Vegetables, Protein, Carbohydrates). The ‘Highland Food Plate – Everyday Eating’ (appendix 3) provides a visual assessment to discuss everyday foods. If any of the four groups are missing from the ‘everyday foods’ or not regularly consumed, then this can be an area for further discussion. Avoid labeling foods as ‘good’ or ‘bad’. Instead distinguish between them by saying one is a food to eat more of or less of. Also avoid referring to highly processed or sugary foods as a ‘treat’ as children may place extra value of them. Instead refer to them as ‘sometimes’ foods which they get to have on occasion but not every day.

Resources

Highland Food Plate – Everyday Eating
Four food groups

Fussy Eating

Fussy eating can be a normal behaviour for young children. The child may eat a lot one day, a little the next, and is unlikely to eat everything from the meal every time. Parents/carers are role models and lead by example as children learn to eat new foods by watching parents/carers eat.  The child will look, touch, taste and spit out their food. Even after a child learns to like a food, they won’t eat it every time. A good deal of patience, persistence and judgment is encouraged. The parent/carer can help young children to accept a variety of everyday foods and lead by example. Consider how the parent/carer can support the child in relation to their environment, meal structure, safety and variety of everyday food. Promoting the parent/carer to encourage the child to tune in, and respond to, their feelings of hunger and fullness (please refer to How to eat - Encourage children to be ‘competent eaters’ section).

Resources

Highland Food Plate – Everyday Eating
Four food groups
Fussy Eating

Constipation

Constipation in children is common.  It is prevalent in 5% to 30% of children.

It may start if the child has been unwell; to changes in diet or fluid intake or while the child is toilet training. Signs and symptoms in children include infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing occasional large stool or frequent pellets, withholding or straining, soiling or overflow or abdominal pain, distension or discomfort, poor appetite, lack of energy, irritable mood and painful toileting (NHS Highland , n.d.), (Constipation in Children and Young People, 2010)

A full assessment should be carried out to identity any areas of concern. Parents/carers should be supported to find solutions which may include:

  • A child should have 6 to 8 drinks of fluid a day, but no more than 500mLs of milk a day.
  • Include fruit, vegetables and pulses in their diet to provide fibre
  • Gradually change low fibre starchy carbohydrates to high fibre carbohydrates, e.g. swap white bread for brown bread or low fibre cereal for high fibre cereal.
  • Regular meals and snacks
  • Encourage physical activity
  • Give praise for using the potty or toilet during potty training, and make sure they have a step for their feet at the toilet to get in a good position to poo.

In general a high fibre diet for children under 2 is not recommended as this may mean that the diet is less calorie dense, resulting in poor growth. However, a child who is growing normally, but is constipated, may benefit from a higher fibre diet.

Resources

Highland Food Plate – Everyday Eating
Four food groups

Food Intolerance / Allergies

Many young children have an allergy or intolerance diagnosed by their parent/carer or paediatrician through observation and trial and error. Families who suspect of food allergy or intolerance may need appropriate supervision to ensure that any dietary exclusions are done safely if they are of a major food such as milk or wheat. Symptoms of allergy or intolerance can include gut disturbance, skin conditions, tiredness or irritability. The most serious result of a food allergy relates to anaphylaxis with the impairment of breathing or collapse which can be life threatening.
Those with severe allergy will need safety protocols in place provided by the child’s paediatrician (Epipen training for home and nursery etc).
Nurseries and schools have an obligation to meet the special dietary needs of children with allergies and intolerances. Council settings have guidance and policies in place to support this, and the health professional giving the recommendation may also provide advice.

Resources
Highland Information Trail http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf
Eating well and body confidence in children
Highland Food Plate – Everyday Eating
Four food groups
Fussy Eaters Please
Conversation Tool for Healthy Weight
Conversation Tool for Physical Activity

Vitamins and minerals

Some children are at particular risk of vitamin deficiency including persistent poor eaters, children who eat a limited number of foods or have a restricted diet due to their choice, allergy or intolerance.

Recommendations
All children age 6 months up to 5 years of age should receive a supplement of Vitamin A, C, and D.  All the following vitamins are contained in Healthy Start multi vitamin drops for children (NHS , n.d.), (NHS Choices, n.d.)

A supplement will help to ensure that a child is receiving enough Vitamin A, C and D.

Vitamin A
Vitamin A helps keep the immune system healthy, can help vision and supports healthy skin.  Good food sources are dairy, fortified fat spreads, carrots, dark green leafy vegetables, sweet potato and mangoes.

Vitamin C
Vitamin C helps the body absorb iron and maintain a healthy immune system.  Eating a healthy, balance diet containing plenty fruit and vegetables will supply sufficient vitamin C for most young people.

Vitamin D
Vitamin D is a fat soluble pro hormone, which is essential for skeletal growth and bone health.  Vitamin D is needed to keep bones and teeth healthy and is particularly important in preventing rickets; it also has a role in illness prevention. Good food sources are oily fish, eggs added to some spreads, and breakfast cereals. The best source of vitamin D is summer sunlight on unprotected skin (Scottish Government , n.d.)

10-15 minutes of unprotected sun exposure in Scotland is safe. It is not recommended to stay in the sun unprotected for long periods of time. (NHS Health Scotland, 2018). Babies and children under 4 need 10 micrograms (ug) a day. (NHS Health Scotland, 2018).

In addition: some young children may lack essential nutrients other than those found in the Healthy Start Vitamin drops. This might include iron, other minerals or Omega 3. It is important that any supplements taken compliment the diet and supervision may be needed to ensure that this is done appropriately (Scientific Advisory Committee on Nutrition , 2015).

Resources
Highland Information Trail  http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf
Healthy Start – Children’s Vitamin drops decision tree
Healthy Start – Insights for Healthy Visitor
Healthy Start – Check list for family with children under 4 years old

Healthy body weight

Healthy weight varies from person to person. An assessment of a young child’s health should not be based on their body shape and size alone. Parents/carers, childcare providers and family support practitioners are key to enabling children to maintain a healthy weight. A healthy body is one that, whatever shape, size, or weight, is in a state of wellbeing, has enough energy, strength and stamina to be active, allows a person to achieve his or her goals, and participate in life.

UK – WHO Growth Charts
The UK WHO Growth Charts are a tool to record the growth of a child aged between two weeks old and four years (Scottish Government , n.d.), (Royal College of Nursing, n.d.)
Body Mass Index (BMI) relates weight to height and is primarily intended as a surveillance tool to track changes in population growth. This provides an approximate BMI centile accurate to a quarter of a centile space (Royal College of Paediatrics and Child Health (RCPCH) , n.d.)
The BMI distribution of children in Primary 1 has remained broadly similar over the period 2005/06 to 2017/18 (Information Service Division Scotland , n.d.)

How to encourage Healthy Body Weight

  • Support children to listen to hunger cues and to eat to appetite
  • Base meals and snacks on ‘everyday’ foods
  • Avoid classifying foods as good or bad
  • Teach children to make the links between eating certain foods and how that makes them feel
  • Comfort children with attention, listening and hugs instead of food
  • Create a non distracting environment, separate eating from other activities
  • Whenever possible eat meals together
  • Ensure children have regular meals, including breakfast

It is helpful for parents to focus on health and personal strengths by promoting the importance of a fit and healthy body, rather than thin or ideal body (Hart, et al., 2014)

Distribution of Children’s Weight, Height and BMI

Within a population children’s weight, height and BMI are all distributed in a Gaussian curve or normal distribution (Fig 1).

Although 50% of children will have a weight, height or BMI which is between 25th and 75th centiles:

  • 4th centile – 0.4% of infants will be below the 0.4th centile.
  • 2nd centile – 2% of infants will be below the 2nd centile
  • 91st centile – 9% of infants will be above 91st centile
  • 98th centile – 2% of infants will be above the 98th centile
Low weight in children
  • Infants recorded as below the 2nd centile may reflect under nutrition. It will be normal for 2 out of 100 infants, but considered along with length/height and head circumference.All children need to consume adequate energy for growth and development.  Sometimes this can be challenging as they eat relatively small amounts of food.
  • Infants recorded as below the 0.4th centile should be assessed in more detail even if apparently growing steadily. It will be normal for 4 in a 1000 infants to be below 0.4th. Poor growth in infancy is associated with high childhood morbidity and mortality. Some children will grow at a low centile which is a normal trend for them; we do not know which children this will be.
High weight in children
  • Infants recorded as above the 91st centile on chart may reflect overweight, however within the normal population 9 out of every 100 infants will be in this group.
  • Infants recorded as above the 98th centile may reflect very overweight, however within the normal population 2 out of every 100 infants will be in this group.
  • Children who are over the 98th centile may warrant further assessment including taking a family weight history and monitoring the trends; for children who show a steady increase in centiles, weight maintenance is an acceptable treatment goal (Scottish Government, Revised September 2009), (Scottish Government, 2004), (Science, 2007).

Weight and Measuring

Children’s growth is regularly measured and assessed throughout the scheduled Health Visitor (HV) contacts. These measurements include weight, height, head circumference and BMI which are all plotted on standard growth charts. Normal growth is when children follow the trajectories; any deviation of 2 or more centiles between height and weight may warrant closer monitoring and further investigation.

Weight
Children under 2 years of age should be weighed, without clothes or nappy.
Children over 2 years of age should be weighed wearing vest and pants but no footwear.

Length / Height
Children under 2 years of age should be measured, without clothes or nappy, using a length board or mat. It is good practice to take 3 measurements and use the average.
Children over 2 years of age should be measured using a rigid upright measure with a T piece or stadiometer.  Always remove footwear.

It is recommended that length and/or height should be measured whenever there are any concerns about a child’s weight gain or loss, growth and general health.

Early learning and childcare setting

Early years services have a valuable role to play in promoting healthy eating to children, parents/carers and the wider community.

Curriculum for Excellence

Many children aged one – five years will spend time in a setting registered with the Scottish Commission for the Regulation of Care (the ‘Care Inspectorate’). Services which require to be registered are: child minders, day nurseries, out of school clubs and Early Learning and Childcare education centers’. Standards are set which services should meet and which form the basis of inspection.

National Care Standard 3 sets out the expectations regarding ‘Health and Wellbeing’ in early education and childcare services up to the age of 16 including:

  • Children and young people have opportunities to learn about healthy lifestyles and relationships, hygiene, diet and personal
  • Children and young people have access to a well-balanced and healthy diet (where food is provided) which takes account of ethnic, cultural and dietary requirements, including food allergies. Staff should make sure that help with feeding is given, in a way that best meets the needs of the child or young person.
  • Children and young people have the opportunity to sleep or rest, and have regular access to fresh air and energetic physical

The ‘Curriculum for Excellence’ includes healthy eating and physical activity topics within the ‘Health and Wellbeing Outcomes’ for the early stage.

Smart Start – North Highland

Smart Start is a programme that has been developed to equip early year’s staff with the tools and confidence to deliver a crucial aspect of a child’s learning and development. At the core of a child’s development are healthy eating, physical activity and self awareness. Smart Start covers this, as well as addressing key experiences and outcomes outlined in curriculum for excellence.

This programme is delivered throughout North Highland. There are relevant session plans and resources available for Smart Start. See website below. 
https://www.careandlearningalliance.co.uk/training-events/smart-start/

Further information

The quality of a child’s early year’s experiences can have an impact upon their physical, emotional and intellectual development. Body confidence embeds healthy eating patterns, fun physical activities and enhances self esteem in children. Care providers should be aware of the challenges that can affect the lifestyle choices made by the parents/carers of young children. 

Resource
Eating Well and Body Confidence in Children – Ideas for Parents and Carers

Social Influences on Weight

Providing a parent/carer with a leaflet on healthy eating for children may not be of sufficient help. Wider stresses on parents/carers and families such as poor housing, employment and income can affect the quality of the early years experience and therefore have an impact on development.  When applicable a discussion about local support networks, Healthy Start eligibility and accessing income maximisation services may be more appropriate (Early Years, n.d.), (Government, 2008)

An understanding of adult services available to help improve the outcomes of children is important.

Income maximisation
The income maximisation team can offer advice about benefits and other entitlements that are available.  They can provide advice and assistance in budgeting and financial matters including debt advice.  An experienced money adviser can check if families are getting all the income they are entitled to, offer budgeting advice and discuss what options are available to help deal with debt.

North Highland - Tel  0800 090 1004 / email income.maximisation@highland.gov.uk 
Argyll and Bute - http://www.argyll-bute.gov.uk/social-care-and-health/welfare-rights

Fuel Poverty
There are a number of energy efficiency schemes for vulnerable households at risk of fuel poverty which offer grants.

North Highland:  Offer a referral scheme for energy and fire safety advice.  Home Energy Scotland contact number as below. 
Highland - Tel:  0808 808 2282

Food Banks
Food banks are a charitable system that provides emergency food supplies for people unable to buy food themselves because of financial distress. There are a number of food banks across Highland.  To receive help from one of these food banks, a referral should be completed by a general practitioner, health visitor, social worker or local citizen’s advice bureau.  A voucher is given to the recipient to take along to their local food bank to exchange for food and recipes to help make the most of the food provided.

North Highland - Tel: 01349 830 777 Email: info@blythswood.org
Argyll and Bute - Tel: 01631 565 730
Oban: Hopkitchen@gmail.com

Family Nurse Partnership
The family nurse partnership for young first time mums offers structured home visiting by specially trained staff until the child is two years old.  It aims to improve child health and development, and the mother’s economic self sufficiency (Family Nurse Partnership , n.d.), (Department of Health , n.d.)

Behaviour change

When discussing what we eat, how we eat and lifestyle issues, information and support should be personalised, relevant, realistic, practical and grounded in a relationship of trust and respect (National Institute for Health and Clinical Excellence , 2014). Please refer to conversation tools based on health behaviour change. See Conversation Tool for Healthy Weight section and Conversation Tool for Physical Activity section.

The use of Health Behaviour Change approaches supports parents and carers to identify suitable changes and ways to make them, rather than having them presented by the practitioner.

  • Opportunities for free NHSH face to face training on Health Behaviour Change using Motivational interviewing can be found at: https://www.nhshighland.scot.nhs.uk/YourHealth/Pages/HealthImprovementTraining.aspx
  • This training programme has been developed by NHS Education for Scotland and is based on the Health Behaviour Change Competence Framework: https://www.nes.scot.nhs.uk/education-and-training/by-discipline/psychology/multiprofessional-psychology/health-psychology/the-map-of-behaviour-change-training-programme.aspx
  • Compassionate Connections is a family focused online learning resource to support a health professional’s role in maternal, newborn and infant health and wellbeing. It can be accessed at http://www.knowledge.scot.nhs.uk/compassion.aspx
  • Introduction to Healthy Weight, Intuitive Eating and Introduction to Child Healthy weight are three courses which take a comprehensive, progressive and holistic view to food, health and healthy weight. There is also a two day ‘Putting it in to Practice’ course to help apply the learning in to different job roles. Opportunities for free North NHSH training on these courses are available for staff and partners available here: https://www.nhshighland.scot.nhs.uk/YourHealth/Pages/HealthImprovementTraining.aspx

Resources
Highland Information Trail http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf
Eating well and Body confidence in Children
GIRFEC 
Conversation Tool for Healthy Weight
Conversation Tool for Physical Activity

Oral health

A child should be registered with a dentist soon after birth and before their 1st birthday.  In addition to good practice at home, many child providers work closely with National Childsmile Programme.
Tooth decay and gum disease is prevented by:

  • Regularly brushing teeth
  • Use of fluoride toothpaste
  • A reduced sugar diet

Childsmile Programme  
Childsmile is a National Programme to improve oral health and modernising NHS Dental services in Scotland (The Scottish Executive , 2005).

The frequent consumption i.e., constant sipping, of acidic or sugary drinks (such as fruit juice, carbonated drinks and diluting juice) should be avoided to help prevent dental erosion. All added sugars in the diet are of low nutritional value.

Within the ‘Childsmile’ programme from birth, the Health Visitor will assess newborn children so that all those considered to have increased risk of dental decay can be enrolled into a programme from the earliest age. Following referral to ‘Childsmile’, the family will be visited by a community based Oral Health Support Worker who will explain the benefits of joining ‘Childsmile’ and link the child into a local dental practice. The Oral Health Support Worker is available to support families to attend the dental practice at the recommended visits and also to link the family into other activities available in the local community that support good oral health (Levine, 2014).

Through ‘Childsmile’, children will receive an enhanced package of infant dental care at their chosen dental practice. The oral health promotion sessions will be run by trained dental care professionals with parents/carers on a one to one or small group basis. It is recommended that visits to a dental practice take place when the child reaches three months, six months and at least six monthly intervals (Child Smile , n.d.)

Resources
Highland Information Trail  http://www.forhighlandschildren.org/4-icspublication/index_169_25627896.pdf

  • Oral Hygiene Pack (at Health Visitor Discretion) COHT
  • Oral Hygiene pack (twice per year at 3 and 4 years of age) COHT
  • http://www.child-smile.org.uk/
Appendix 1 - Eating well and body confidence in children

A well balanced diet and an active lifestyle can positively affect physical, mental and emotional wellbeing. This is true for children of all shapes and sizes.

  • Parents/Carers focus on making a nutritious and varied diet available, rather than attempting to micromanage how much a child eats.
  • Parents/Carers lead by example and model the enjoyment of the most nutritious and well balanced diet they can provide
  • Families eat meals together when they can.
  • Parents/Carers model and encourage an active lifestyle, with an emphasis on enjoyment rather than “calorie burning”.
  • If a child has their weight measured by a health professional, and it is well above or well below the “Ideal healthy weight range”, a conversation about what might be influencing weight can take place.
  • Very often, heavier children (with a high BMI), are actually eating a varied and nutritious diet.
  • Children (and adults) often need to re-learn how to tune into their body’s natural sense of hunger and fullness.
  • Ideally, a child will eat when they are hungry and stop when they are full! This is better than dietary restraint or eating with abandonment.
  • The pursuit of weight loss (dieting) is not recommended as it leads to weight gain in the long term.
  • Parents/Carers encourage their children to be confident about their own bodies, emphasising that not everyone should be the same size or shape.
  • Parents/Carers lead by example. “Diet talk” or judgments on people’s size or shape may not be helpful.
  • Sometimes children may be bullied because of their size or shape; weight loss is not the answer - bullying is never acceptable
  • Parents/Carers and older children are advised that health gain through better food and physical activity choices, is achievable with or without a change in body size or shape.

Co-Author – Dave Rex, Specialist Dietitian, Care & Learning Directorate

Appendix 2 - Getting it right for every child

The approach helps practitioners focus on what makes a positive difference for children and young people – and how they can act to deliver these improvements. Getting it right for every child is being threaded through all existing policy, practice, strategy and legislation affecting children, young people and their families.
This means working across organisational boundaries and putting children and their families at the heart of decision making – and giving all our children and young people the best possible start in life. The ‘my work triangle’ ecological model then assists practitioners to undertake a fuller assessment.  Identifying the strengths and resources for a family and providing an analysis of their need.

Appendix 3 - Highland Food Plate - everyday eating


Highland Food Guide –
full resource available on NHS Highland website and to order via http://healthyhighlanders.co.uk/HPAC/Index.jsp

Appendix 4 - Everyday food - four food groups

Group 1

Carbohydrates

All types of bread, potatoes, pasta, rice and breakfast cereals and other starchy foods

Group 2

Fruits & Vegetables

Fruit and vegetables in all forms, whether fresh, frozen, canned, dried and pulses

Group 3

Protein

Meat and fish whether fresh, frozen or canned; eggs, nuts, seeds, pulses and beans.  Oily fish includes fresh, smoked, canned or frozen salmon, mackerel, trout, herring, sardines or pilchards and fresh and frozen tuna

Group 4

Dairy

Milk, cheese, yogurt, fromage frais or calcium fortified plant based alternatives.

Plan meals and snacks around the four food groups to help provide a variety of foods.

Note:  The quantities of food a child wishes to eat may vary greatly from child to child. Few children want to eat the same amount every day.

Appendix 5 - A simple guide to choosing milks for toddlers

Milks suitable for use

TODDLERS 1 to 2 YEARS

Breast milk

Yes

Whole cows’ milk (or goats’ milk, buffulos’ milk, sheeps’ milk or unsweetened calcium fortified soya milk or milk alternative) as main milk drink (Non animal milks may lack Iodine and protein so professional advice may be needed)

Yes

Infant formula suitable from birth

(cows’ or goats’ milk protein based)

Seek Advice from Health Professional

Infant formula marketed for hungrier babies, suitable from birth (cows’ milk based)

Seek Advice from Health Professional

Thickened (anti-reflux) infant formula suitable from birth, made up at 70 degrees Celsius

Seek Advice from Health Professional

Thickened (anti-reflux) infant formula suitable from birth, made up at less than 70 degrees Celsius without medical advice

X

Soy protein based infant formula suitable from birth

Seek Advice from Health Professional

Lactose-free infant formula suitable from birth

Seek Advice from Health Professional

Partially hydrolysed infant formula suitable from birth

Seek Advice from Health Professional

Follow-on formula suitable from 6 months of age (cows’ milk or goats’ milk based)

Seek Advice from Health Professional

Good night milk

Seek Advice from Health Professional

Growing-up milks and toddler milks suitable from around 1 year of age (cows’ milk or goats’ milk based)

Seek Advice from Health Professional

Growing-up milks and toddler milks suitable from around 1 year of age (soya protein based)

Seek Advice from Health Professional

PaediaSure Shake for fussy eaters

X

Growing-up milks and toddler milks suitable from around 2 years of age

Not before 2 years. Seek advice from 2 years +

Whole goats’ milk

Yes

Whole sheeps’ milk

Yes

Unsweetened calcium-fortified soya milk, almond milk or oat milk

Yes But seek advice to ensure the diet is sufficiently energy dense

Rice milk – do not give this milk to children under the age of 5 years

X

Yes - safe to give
X
- Do not give this milk

Infant milks: A simple guide to infant formula, follow-on formula and other infant milks, Published by First Steps Nutrition Trust, January 2015. A PDF of this resource is available on the First Steps Nutrition Trust website www.firststepsnutrition.org (section 2, page 1).

Appendix 6 - Fussy eating
  • Avoid making changes when a child is anxious. Anxiety will just make a child more likely to reject change
  • Try to avoid negotiating pleading and too much explanation. This often just increases anxiety
  • Limit the length of the meal. Mealtimes should not be rushed. At the same time, most children do not need more than 15 to 30 minutes to eat a meal. It is sometimes helpful to create a rule where any food that is not eaten is thrown away after 30 minutes.
  • Be realistic. One child can manage a plateful of new food, another will cope with a few mouthfuls. For some children, success is simply putting in the mouth and then removing it. The next time it is offered it will be more familiar and acceptable.
  • Make the foods you want your child to eat seem more valuable. You can do this by appearing to restrict it... For example, we often say “Oh alright then, you can have a biscuit - but only one”. This often backfires, with the child wanting lots because you said they could only have one, so its value was increased. Why not try restricting something more nutritious like meat, fish, fruit or vegetables. This can make these foods seem more valuable too.
  • Take the pressure off. Put food that is unfamiliar on child’s plate. Do not ask the child to eat it. If they refuse, sometimes it is best just to say, “That’s fine, you eat what you want to. Leave that bit if you don’t like it”. Appearing not to care too much will help reduce any anxiety. Alternatively, put the foods you want the child to try on serving dishes so that they can help themselves. They are most likely to do this when you are not looking!
  • Involve children in choosing which foods to buy prepare or cook. This helps to show children that they have some control and can make choices. For example, when shopping, tell the child to choose three new foods. To start with, these choices may not be that nutritious. This is not important. The child is just learning that trying new food is something that they have control over and that can be enjoyable. It may even be best not to ask the child to eat the food they have chosen when you get home. Leave it out so the new food can be seen. When the child sees the food that they have chosen, there is a chance that they will ask if they can have it. Similarly, if a child helps with preparing and cooking food, there may be no need to ask a child to try some. If they want some, they will either eat it or ask if they can have it.
  • Praising children. You can praise children for trying something However, do not overdo it. Praise them in a ‘matter of fact’ way that is not too emotional. Too much expression may just remind the child what a big deal it is and make them anxious.
  • Dessert. Children often enjoy dessert more than the main course. This means that parents/carers often only allow dessert if the main course has been eaten. This is not always a good idea. It can create the idea that the main course is an unpleasant thing that has to be endured before they get what they really want.
  • Influence of other children. Avoid giving too many snacks immediately before a meal. Children eat better when they are hungry, but not too hungry. Try to leave at least an hour between a snack and a meal

Produced by Dave Rex- Specialist Dietitian, Care & Learning Directorate

Appendix 7 - Healthy start - Children's vitamin drops decision tree


For the most up-to-date advice on Vitamin D from birth see the
Scottish Government website

Appendix 8 - Healthy start - Insights for health visitor

Appendix 9 - Healthy start - Checklist for family and children under 4 years old

Appendix 10 - Conversation tool for eating well



Pathway produced by: Beverley Green,
Healthy Eating choices and Body Confidence with Children age 1 to 5 Guidance 2016

Appendix 11 - Conversation tool for physical activity



Pathway produced by: Beverley Green,
Healthy Eating choices and Body Confidence with Children age 1 to 5 Guidance 2016

Appendix 12 - Vegetarian and vegan diets

Diets based on a variety of plant based foods can be tasty and nutritious. Most nutrients can be found in adequate amounts in plant based foods. However, some important nutrients to consider are vitamin B12, omega 3 fats, the minerals: iron, calcium and iodine; and protein.

Vitamin

B12

Found mostly in foods of animal origin (including dairy). A vegan diet is likely to be deficient in this vitamin unless it is taken as a supplement or consumed twice a day in foods that have been fortified with B12. Some milk substitutes, soya yoghurts and breakfast cereals are fortified with B12. Check the label. Yeast extract is also a good source but is very high in salt.

Iron

Essential for healthy blood. Intakes of Iron among vegetarians and vegans sometimes look OK, but the absorption of Iron from non-meat sources can be quite poor. Therefore it is especially important that vegetarian and vegan diets contain plenty of Iron rich foods like  green vegetables, pulses and fortified breads and breakfast cereals. For vegetarians, eggs are an excellent source of Iron.

Omega 3 fats

The kind found in oily fish are especially useful for the developing brain. The body can convert some of the omega 3 fats found in rapeseed oil, flaxseed, walnuts, chia seeds and green leafy vegetables. However, this conversion is not very reliable. Omega 3 fats of similar quality to those found in fish are also found in supplements made from algae.

Iodine

Required for brain development and thyroid function. It is found mostly in milk, yoghurt, eggs and fish. A diet that excludes these foods may well be deficient in Iodine. It is found in some multivitamin and mineral supplements that are suitable for toddlers. Check the label. Iodine is sometimes added to fortified milk substitutes made from oats, coconut, soya, almond, hemp etc. It varies from brand to brand so once again, check the label. It is also possible to buy table salt that has had Iodine added. This can be used in cooking or at the table in the same way as regular table salt.

Calcium

Needed for healthy bones. A dairy free diet is sometimes deficient in calcium. Good dairy free sources include tofu, green leafy vegetables, some dried fruits and nuts, sesame seeds, tahini, fortified milk substitutes and yoghurt substitutes. Note that organic dairy substitutes usually are not fortified with calcium.

Protein

Meat, fish, eggs and most dairy products have what is known as “High biological value” protein. This means they contain the essential amino acids we require from our diet. A vegan diet can contain enough high biological value protein, provided the diets includes a variety of protein sources. Good sources of protein include chick peas, beans, lentils, quinoa, tofu, nuts and seeds and “butters” made from these.

Fibre

One of several potential health benefits of vegetarian and vegan diets is that they are higher in fibre. This is good for healthy gut function and may also have wider benefits. However, too much fibre for pre-school children, can limit the ability of the gut to absorb enough Iron and Zinc. These minerals are often already lower in vegetarian and vegan diets because red meat is one of the richest sources of these minerals. Make sure, therefore, that some of the starchy foods your toddler eats are of the low fibre kind. Including some high fibre versions is fine.

Produced by Dave Rex- Specialist Dietitian, Care & Learning Directorate

Appendix 13 - Needs assessment

Discussion with Child Care Providers 
Discussions with over 150 child care providers including the Early Years and Childcare settings, partner centres, foster/adoption services, and also childminders, health visitors and other health, social care and educational staff were conducted around their needs in the provision of food and health interventions.  The child care providers were from a number of disciplines and based in a variety of different locations throughout the area; including Argyll and Bute, Inverness, Caithness, Sutherland, Easter Ross, Lochaber, Skye, Lochalsh and Wester Ross.
The needs assessment was initially carried out for children age one to three years. During discussion with all stakeholders it was quickly identified that this guidance should address food and health in children aged one to five years.    
Constraints described by staff included lack of time and large case loads, and therefore the need for succinct and easy to access resources was identified.
Foster / adoption services described their concerns about the lifestyle behaviours of the young children in their care.  These children have potentially had a lack of: routine, healthy eating patterns and vitamin drops. They may have had a difficult start to life, which has a knock on effect on their vulnerability and their trust in society. Foster / adoption services also highlighted young children from multi cultural backgrounds, as a particular concern.

Discussion with Carers
Carers were accessed at a selected sample of nurseries and toddler groups throughout the area including Inverness, Lairg, Fort William, and Wick.  The carers interviewed were mainly mothers, and their families had a range of ages. Carers were asked a number of questions related to child nutrition.
Carers reported that information regarding healthy eating was mainly accessed and received from family, the media and health professionals. Recurrent issues were confusion about healthy eating because of mixed messages in the media. They wanted further discussion with health professionals about healthy eating choices and behaviours, like fussy eating.

Reviewing the literature
A literature search was undertaken which included:

  • the role and impact of healthy weight interventions in Early Learning and Childcare
  • preventing body dissatisfaction in children

The research demonstrates that even though young children may display levels of body dissatisfaction, poor body image and the beginning of disordered eating patterns from a young age, it is not as consolidated in young children as it is in adolescents (Smolak, 2004). There are many opportunities during the Early Learning and Childcare years for prevention orientated interventions working in conjunction with parents/carers to promote positive body image, good self esteem and healthy eating behaviours, resulting in resilient children and improved health outcomes for later life. It is clear from the literature review that interventions around children’s weight need to be approached from a health centred perspective rather than a weight centred perspective - focusing on health gain rather than weight loss (Hart, et al., 2015).

Appendix 14 - List of recommendations
Healthy body image Help children to feel confident about their bodies by encouraging a well balanced diet and an active lifestyle; this can positively affect physical, mental and emotional wellbeing for children of all shapes and sizes
Fluid What to drink - 6 to 8 drinks of 100mL to 150mL of fluids/per day, suitable fluids include water or milk. 
How to drink - use an open cup where possible
Eating Well What to Eat - A variety of everyday food based on the four food groups, carbohydrates, fruit and vegetables, protein, dairy
How to Eat - Tune into senses of hunger and fullness and stop when full.  It is advised not to force a child to eat when they are not hungry. Share meals together with your child whenever possible.  The parent/carer is responsible for providing food, when the child eats and where the child eats. The child is responsible for how much they eat and whether they want to eat.
Dentist A child should be registered with a dentist soon after birth and before their 1st birthday
Vitamins Parents/Carers should speak to their health visitor about a suitable supplement for the age of their child.
Physical Activity 180 minutes of activity / day should be spread through the day rather than one long session. Physical activity should be enjoyable and engaging.
Appendix 15 - Further information

NHS Highland Leaflet

Eating Well for Child Health & Wellbeing - https://www.nhshighland.scot.nhs.uk/YourHealth/Documents/HealthyWeight/EverydayEatingForChildrenFlyer-DigitalVersion.pdf

Nutrition

Childsmile national programme designed to improve general and oral health and reduce health inequalities www.child-smile.org
Food Standards Agency. Available www.food.gov.uk/about-us/publications/safetyandhygiene
First Steps Nutrition www.firststepsnutrition.org lots of advice and information on healthy eating from pregnancy and birth
Healthy Start www.healthystart.nhs.uk NHS Health Scotland.
Ready steady Toddler! Is the national booklet for parents/carers covering 13 months – three years www.nhshighland.scot.nhs.uk/HIRS (Available as an APP)
Setting the table - http://www.healthscotland.com/documents/30341.aspx

Physical Activity

play@home

Physical activities are offered at:
North Highland https://www.highlifehighland.com
Argyll and Bute www.argyll-bute.gov.uk.

Body Confidence

Ellen Satter http://www.ellynsatterinstitute.org/

Hart LM, Damiano SR, Paxton SJ and Jorm AF. Preventing body dissatisfaction and unhealthy eating patterns in children: strategies for parents of preschoolers. La Trobe University, Melbourne 2014

Sigrun Danielsdottir. Your body is Brilliant. Jessica Kingsley Publishers

Resources

North Highland www.nhshighland.scot.nhs.uk/ HIRS 01463 704647  www.forhighlandschildren.org
Argyll and Bute: Public Education resource library, Dykebar Hospital, paisley  0141 314 4261, Oban education office 01631 564 908

Building the Ambition - http://www.gov.scot/Resource/0045/00458455.pdf

Bumps to Bairns https://bumps2bairns.com/food-and-health/

TRAINING OPPORTUNITIES FOR NHS HIGHLAND STAFF

  • Health Behaviour Change using Motivational interviewing can be found at: https://www.nhshighland.scot.nhs.uk/YourHealth/Pages/HealthImprovementTraining.aspx
  • Compassionate Connections http://www.knowledge.scot.nhs.uk/compassion.aspx
  • Introduction to Healthy Weight and Intuitive Eating  https://www.nhshighland.scot.nhs.uk/YourHealth/Pages/HealthImprovementTraining.aspx
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Editorial Information

Last reviewed: 30 January 2020

Next review: 30 January 2023

Author(s): Health Improvement Specialist

Version: 2

Approved By: Food, fluid and nutritional care (FFNC) steering group

Reviewer Name(s): Health Improvement Specialist

Document Id: TAM204