Eating well for under-5s in child care · Eating Well for Under-5s in Child Carewas originally...

Eating well for under-5sin child care

Practical and nutritional guidelines

Second Edition

By Dr Helen Crawley

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© The Caroline Walker Trust, 1998, 2006

First edition: ISBN 1 897820 07 0This edition: ISBN 1 897820 21 6

Published by:

The Caroline Walker Trust PO Box 61St Austell PL26 9YLwww.cwt.org.uk

Registered charity number: 328580

Edited and produced by Wordworks, LondonW4 2HY.

Design by Information Design Workshop.

Cover illustration based on a drawing byMatthew, aged 4.

The text and tables in this report can bephotocopied by anyone involved in providingfood for under-5s, provided that anacknowledgement is made to the CarolineWalker Trust.

Further copies of this report are availablefrom: The Caroline Walker Trust22 Kindersley WayAbbots LangleyHerts WD5 0DQwww.cwt.org.uk

For details of other publications from theCaroline Walker Trust see www.cwt.org.uk

AcknowledgementsThe Caroline Walker Trust would like to thank the Food Standards Agency forfunding the updating of the Eating Well for Under-5s in Child Care report.

This second edition of the report was written by Dr Helen Crawley. Thanks are dueto all those who were involved in the production of the 1998 edition of this report,particularly Anne Dillon-Roberts and the other members of the Expert WorkingGroup (see below).

Thanks are also due to all those who kindly reviewed this second edition, inparticular: Jamie Blackshaw and colleagues at the Food Standards Agency, AnneDillon-Roberts, Helen Glyn-Davies, Judy More, Richard Watt and Martin Wiseman.Special thanks also go to Gemma Hoffman for her help in preparing the samplemenus in chapter 6.

Members of the Expert Working Group

These are the members of the Expert Working Group which produced the first edition of thisreport. Their affiliations are as at 1998 when the first edition was published.

Anne Dillon Roberts (Chair) Trustee of the Caroline Walker Trust

Diane Brown Operations Director, Apetito Services, Apetito Group

Chris Dallimore Principal Registration and Inspection Officer (Children), Sefton Borough Council

Pauline Emmett Head, Nutrition Team, Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC), University of Bristol

Gill Haynes Chief Executive, National Childminding Association

Dr Margaret Lawson Senior Lecturer in Paediatric Nutrition, Institute of Child Health, London

Morag MacKellar Head of Nutrition and Dietetics, Central Scotland Healthcare NHS Trust

Margaret Mason Task Chair for Quality, Registration and Inspection, National Private Day Nurseries Association

Maggie Sanderson Principal Lecturer in Nutrition and Dietetics, University of North London, and Chair of the Caroline Walker Trust

Jane Thomas Lecturer, Department of Nutrition and Dietetics, King’s College,London

Dr Richard Watt Senior Lecturer, Department of Epidemiology and Public Health, University College London

Advisers

Professor Dame Barbara Honorary Research Professor in Metabolism, University ofClayton Southampton

Professor Aubrey Sheiham Professor of Dental Public Health, Department of Epidemiologyand Public Health, University College London

Ann Robinson Early Childhood Unit, National Children’s Bureau

Marion Witton Chair, National Heads of Registration and Inspection Units

Observers

Dr Petra Clarke Department of Health

Dr Jennifer Woolfe Ministry of Agriculture, Fisheries and Food

Secretariat

Dr Helen Crawley Writer and researcher

Rosie Leyden Editor, Wordworks

Sarah Ivatts Administrator

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Foreword

The Caroline Walker Trust is dedicated to the improvement of publichealth through good food. Established in 1988 to continue the workof the distinguished nutritionist, writer and campaigner CarolineWalker, the Trust is a charity which undertakes specific projects as aresult of grants and donations. A major part of our work is to produceexpert reports which establish nutritional guidelines for vulnerablegroups. Eating Well for Under-5s in Child Care was originallyproduced by the Trust in 1998, and has been widely used in publichealth nutrition since that time.

The impetus for the original expert report came from a recognitionthat increasing numbers of under-5s were spending long periods oftime in child care outside their own homes – in local authority orprivate nurseries, with childminders, or in other forms of child care.This continues to be the case, and while there has been a significantincrease of interest in the importance of eating well among the earlyyears sector, the need for clear, evidence-based information for thisgroup remains essential.

There is evidence that the diets of under-5s in the UK are too low invitamins A and C, too low in iron and zinc and, for some groups ofchildren, too low in vitamin D. Children’s diets also contain too fewfruits and vegetables, too much of the type of sugars that mostcontribute to tooth damage, and too much salt. However, until thepublication of the first edition of this report in 1998 there were nonutritional guidelines for food prepared for children in childcaresettings across the UK. Recent work in Scotland has produced food-based and nutrient-based standards for use in nursery care which areto be welcomed and the Caroline Walker Trust (CWT) urges all areasof the UK to make clear, nutrient-based standards for under-5s in childcare a mandatory part of the framework of care we offer. Nutrient-based standards pioneered by CWT have been adopted for schoollunches across the UK and we hope that in other areas of public life,where there is a duty of care to those for whom food is provided,there will be recognition that nutrient-based standards are the simplestand most flexible way of ensuring people eat well. We believe thatnutrient-based standards are simple and manageable and in chapter 6we give a detailed explanation of how they have been calculated andwhy we encourage their use.

Healthy eating and physical activity are vital for proper growth anddevelopment in childhood. Those who provide child care are in aunique position to have a positive influence not only on thenutritional intake of these children but also on the knowledge andattitudes the children have towards food and a healthy lifestyle. Wehave been very encouraged and impressed by the support andenthusiasm of those who provide child care. They clearly recognisethe important role they can play in encouraging healthy developmentthrough good food. We hope that this second edition of our reportwill be used as the basis for the promotion of healthy, balanced dietsfor the under-5s and that our new, more comprehensive nutritionalguidelines are accepted as standards for children in child care.

Joe HarveyChair of the Caroline Walker Trust

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Chapter 1 Summary and recommendations 6

Chapter 2 Why nutritional guidelines are needed 14The diet of under-5s in Britain 14

Under-5s in child care 14

Food provision in child care 15

Aims of this report 17

Who the report is for 17

Chapter 3 Nutrition and 1-4 year olds 19Energy (calories) 20

Fat 21

Carbohydrates 22

Protein 24

Fibre 25

Vitamins 26

Minerals 32

Chapter 4 Infant nutrition 38Milk for babies 38

Weaning (starting on solid foods) 40

Drinks for infants 42

Chapter 5 Encouraging children to eat well 44Eating a variety of foods 44

Fruit and vegetables 45

Food for all 46

Physical activity 46

Drinks for the under-5s 47

Dental health among the under-5s 50

Commercial foods for babies and children 51

Vegetarian diets 51

Special diets 52

Dairy-free diets 52

Food allergy 52

Diet, behaviour and learning in children 53

Children with special needs 53

Food safety and good hygiene 53

Eating patterns and timing of meals and snacks 54

How carers can encourage eating well 55

Dealing with food refusal 56

Learning through food 56

Listening to children 57

Involving and listening to parents and guardians 57

Bringing food from home 58

Food for special occasions 58

Developing a nutrition policy 59

Healthy eating awards 60

Contents

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Contents

Chapter 6 Nutritional guidelines and menu planning 61Why nutrient-based standards are the most

effective way to improve menu planning 61

How the nutrient-based standards have been calculated 62

Nutrient-based standards for food prepared for 1-4 year olds

in child care: SUMMARY OF RECOMMENDATIONS 65

How do the standards translate into specific nutrients

for groups of children of different ages? 66


in child care 66


in child care 67


in child care 68

Recommendations for menu planners 69

Sample menus 72

Cost factors 73

Appendix 1 National Standards for Childcare 76

Appendix 2 Good sources of vitamins and minerals 78

Appendix 3 Dietary Reference Values for energy and nutrients

for under-5s 81

Appendix 4 Food-related customs 83

Appendix 5 Useful addresses and further information 84

Index 88

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Chapter 1 Summary and recommendations

SummaryThis report deals with children upto their fifth birthday. The terminfants applies to children up to12 months. The term under-5sapplies to 1-4 year olds – ie.children from the age of 12months up to their fifth birthday.The term carers applies to staffworking in child care and earlyyears settings including localauthority and private nurseries,and childminders.

Healthy eating and physicalactivity are essential for propergrowth and development inchildhood. To help childrendevelop patterns of healthy eatingfrom an early age, it is important

We are eating our lunchSiân, aged 5

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that the food and eating patternsto which they are exposed – bothat home and outside the home –are those which promote positiveattitudes to good nutrition.

Growing children need plenty ofenergy (calories) and nutrients toensure they grow and developwell, and they need to eat a goodvariety of foods, including lots offruits and vegetables, to makesure they get all the otherimportant dietary componentsthey need. A good appetite willusually make sure they getenough energy from the foodthey eat. However, there isevidence1 that:

• the diets of children under 5 inBritain are:– too low in vitamin A– too low in vitamin C– too low in iron – too low in zinc, and

• their diets contain: – too much of the type of

sugars that most contribute to tooth damage, and

– too much salt, which can contribute to higher blood pressure.

In addition, some children in theUK have low vitamin D statuswhich can lead to poor bonehealth.2

Intakes of meat, fish, vegetablesand fruit are generally low. Anincrease in the intakes of thesefoods would help to ensure thatchildren have the right amountsof vitamins, minerals and otherdietary components for healthygrowth and development.

Eating is an important part ofeveryone’s life. Encouragingchildren to eat healthily does notmean denying them food theyenjoy. Healthy eating is aboutgetting a varied, balanced dietand enjoying lots of differentfoods.

Under-5s in child care

The number of children whospend some time being cared foroutside the family home has risendramatically in recent years. In2005 it was reported that therewere over 1.5 million registeredchildcare places in Englandcompared with around 637,000 in1997 3 and of these 21% werewith childminders, 52% in daycare nurseries and 24% in out-of-school clubs. (Child careprovision in Scotland, Wales andNorthern Ireland is summarised inchapter 2.) Day care providerstherefore supply an increasingproportion of the total food eatenby a considerable number ofchildren across the UK, many ofwhom will be under 5 years ofage.

The way forward

In 1998 the Caroline Walker Trustidentified a need for clear,practical guidelines whichencourage healthy eating amongthe under-5s in child care. Withthe support of the Department ofHealth, the Trust brought togetheran Expert Working Group toproduce nutritional guidelineswhich were published in the firstedition of Eating Well for Under-5s in Child Care. This secondedition, which has beensupported by the Food StandardsAgency, provides updatedguidance and morecomprehensive nutrient-basedstandards. These indicate theproportion of energy andnutrients that should optimally beprovided during child care.Specific nutrient-based standardsare given for food prepared for:

• 1-4 year olds in full-day orhalf-day child care, or for thosehaving individual meals andsnacks while in child care

• 1-2 year olds in full-day orhalf-day child care, or for thosehaving individual meals andsnacks while in child care, and

• 3-4 year olds in full-day orhalf-day child care, or for thosehaving individual meals andsnacks while in child care.

The nutrient-based standards areshown and explained in chapter6. Information on nutrition –which readers may find helpful ininterpreting the nutrient-basedstandards – is given in chapter 3.Chapter 6 also gives some food-based guidance for menuplanners as well as some samplemenus which meet the nutrient-based standards. These will givereaders an idea of how thestandards can be translated intopractice. Additional practicalinformation on how the standardscan be achieved can be found inEating Well for Under-5s in ChildCare: Training Materials.4

This report also givesrecommendations about foodchoice and food service andabout the importance of physicalactivity. The provision of a wellbalanced diet to infants andunder-5s is crucial to children’shealth and wellbeing. TheCaroline Walker Trustrecommends that the nutrient-based standards and otherrecommendations contained inthis report should becomestandards for child care and thatthey should inform those whoinspect and register childcareprovision.

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RecommendationsThe following recommendations apply to 1-4 yearolds (ie. children aged between 12 months up totheir fifth birthday), unless otherwise specified.Separate recommendations for infants up to theage of 12 months are given on page 12.

Nutritional guidelines

1 Nutrient-based standards for food for under-5s inchild care are given on pages 65-68 of thisreport. These should become standards for childcare across all settings.

2 Government departments should includereference to these nutrient-based standards in allguidance and legislation affecting child care.

3 Government, local authorities and otherproviders such as Sure Start and Children’sCentres should include nutrition and nutrient-based standards in development plans forchildren under 5 in child care, and in plans forearly years services and education.

4 The recommendations in this report should beused as part of the training guidance to all thosewho inspect nurseries, crèches, out-of-schoolcare and childminders.

5 All those who inspect childcare services in theUK should monitor the nutritional standards ofthe food served in the childcare and other earlyyears settings they visit. Inspectors’ reportsshould include comments on food and nutrition.Any childcare setting that does not meet thestandards should seek advice from a registereddietitian or registered public health nutritionist.

6 Childcare and other early years settings shouldbe required, as part of the registration process,to demonstrate that they are committed toproviding food which meets the standardsoutlined in this report.

7 Inspectors should look for managementcommitment to good nutrition and encouragechildcare settings to engage in suitable nutritiontraining for all staff. Nursery owners, managers,caterers, childminders and others responsible forearly years services should seek appropriateinformation and training on how to meet thenutrient-based standards.

8 NVQs, SVQs and the Certificate in Childcare andEducation (CCE) are important trainingopportunities for carers and other early yearsstaff. Qualifications for those caring for under-5sshould contain an appropriate section onnutrition and healthy eating which allowsstudents to understand the nutritional guidelinesin this report.

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9 The European Commission should take accountof the nutrient-based standards in this reportwhen looking at European-wide nutritionalstandards for under-5s within the Community.

Eating for health

10 Children should be encouraged to eat a varieddiet. They should eat foods from each of thefour main food groups every day. The four mainfood groups are:• bread, other cereals and potatoes • fruit and vegetables• milk and dairy foods, and• meat, fish and alternatives such as eggs,

pulses (peas, beans and lentils) and soya.

A varied diet is associated with better health as itis more likely to contain all the nutrients thebody needs.

11 Fruit and vegetables are particularly importantfor good health. Under-5s should be encouragedto taste at least five different fruits andvegetables a day.

12 Vitamin C is important in maintaining goodhealth and may have a role in helping the bodyto absorb iron if both nutrients are present inthe same meal. Under-5s should be encouragedto eat foods containing vitamin C at meals – forexample most fruit and fruit juices, potatoes,broccoli and other green vegetables, tomatoesand peppers.

13 It is recommended that children up to the age of5 years should receive vitamin drops containingvitamins A, C and D. This is the responsibility ofthe parents or guardians but carers couldprovide information to parents and guardiansabout where to find out more about them.

14 The iron intake of children under 5 is lowerthan currently recommended and there isevidence to suggest that low iron status iscommon in this age group. Under-5s shouldtherefore eat a diet that is high in iron-rich foodsuch as meat, poultry and fish, as well as fruitsand vegetables. (Meat and meat dishes are alsoa good source of zinc.) Children who do not eatmeat should have a varied diet containing foodssuch as cereals, pulses (peas, beans and lentils),vegetables and fruits.

15 The intakes of the type of sugars in the dietwhich most contribute to tooth decay are higher

than recommended among the under-5s. Ifchildren have sugary foods, these should begiven with meals rather than as snacks betweenmeals. Children do not need sugary foods suchas sweets, chocolate, soft drinks or honey forenergy. Starchy foods – such as potatoes, bread,rice, pasta and yam – are better sources ofenergy (calories) as these foods contain otherimportant nutrients too.

16 It is important that the under-5s get enoughenergy (calories) for growth and development.While adults and children aged over 5 areencouraged to eat a diet that is high in starchyfoods and low in fat, younger children on thissort of diet may not have the appetite to eatenough food to provide all the nutrients theyneed. Carers should therefore be sensitive to theneeds of children who are fussy eaters or smalleaters and ensure that these children are offereda good variety of food that they will accept.

Physical activity and outdoor play

17 Children should be encouraged to be physicallyactive and carers should timetable periods ofactivity into the children’s daily routinethroughout the year. Physical activity helps toensure that children eat enough food and get allthe nutrients they need. It also builds up musclestrength and overall fitness, develops physicalskills such as balance and coordination, andprovides a release for children’s energy.

18 It is essential that there is outdoor space wherechildren can play, or access to an outside areasuch as a garden, park or other safe openspace. Exposure to summer sunlight in outdoorplay helps children to maintain their vitamin Dstatus. However, childcare settings should havea ‘sun policy’, with guidelines on how longchildren can remain outdoors in strongsunshine, and on the use of protective clothingsuch as sunhats, and a sun screen. All under-5sshould be appropriately supervised at all timeswhile outdoors.

19 Children in child care should have access to toysfor active play – for example balls, hoops andskipping ropes.

Drinks for 1-4 year olds

20 Children should be encouraged to drink tapwater if they are thirsty. Water quenches thirst,

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does not spoil the appetite, and does notdamage teeth.

21 Milk is a good drink for 1-4 year olds. Wholecow’s milk is suitable as a main drink for mostchildren from 12 months of age. Semi-skimmedmilk can be introduced gradually after the ageof 2 years, provided that the child is a goodeater and has a varied diet. Skimmed milk is notsuitable as the main drink for children under 5years of age.

22 Diluted fruit juice is a useful source of vitaminC. Children should be encouraged to have aglass of diluted fruit juice with their main mealor with breakfast as this may also help the bodyto absorb iron.

23 Children should be discouraged from havingfizzy drinks and squashes (including fruitsquashes and fruit juice drinks), including diet,non-diet and low-sugar varieties, as these canerode the tooth enamel and contribute to toothdecay. Also, they provide little in the way ofnutrients, and children who drink themfrequently may have less appetite to eat well atmealtimes.

24 If children are given soft drinks (such assquashes) containing the intense sweetenersaccharin, these should be diluted more thanthey would be for an adult or older child – forexample, 1 part squash to at least 10 partswater.

25 Children who bring their own drinks to childcare should be encouraged to bring a plasticflask or a lidded plastic cup containing anappropriately diluted drink. Many ready-to-drinkcartons of squashes, fruit drinks and fruit juiceshave a high sugar content and cannot be dilutedif they are drunk straight from the pack.

26 Tea and coffee are not suitable drinks for under-5s as they contain tannic acid whichinterferes with iron absorption.

Dental health

27 If children are having sugary foods and drinks,these should be given with meals rather thanbetween meals. This is because children’s firstteeth are prone to decay if they are frequentlyin contact with sugars. It is important to reduceboth the frequency and the total amount ofsugar and sugary foods that children eat.

28 To help the healthy development of teeth,children should not be given sweet drinks (suchas fruit juice, squashes and other soft drinks) ina bottle or dinky feeder. An open cup or beakerwhich does not require the child to suck shouldbe used if these drinks are given with meals.

29 If a child uses a dummy or comforter, it shouldnever be dipped into sugar or sugary drinks, asthis can contribute to tooth decay.

30 Some soft drinks which claim to have ‘no addedsugar’ still contain sugars which are harmful tothe teeth. Diet drinks, both fizzy and still, canalso be harmful to the teeth. This is becausethey may be acidic and erode the dentalenamel, especially if sipped frequently. The useof these drinks should be avoided.

Food hygiene and safety issues

31 Carers should always wash their hands withsoap and water before preparing food orhelping children to eat, and after changingnappies and toileting children. If carers use ahandkerchief while preparing food, they shouldwash their hands before continuing.

32 Children’s hands should always be washed withsoap and water before meals and snacks, andafter going to the toilet.

33 Carers need to be aware of the requirements ofthe Food Safety Act. Some carers may need tocomplete a Food Hygiene Certificate course.Further information on this can be obtainedfrom the local authority’s environmental healthdepartment, or from its registration andinspection unit.

34 Carers also need to be aware of food safetyissues such as storage of food and use ofleftover food, and thorough cooking or heatingof foods. Several useful publications areavailable from the Food Standards Agency (seeAppendix 5). Carers should obtain and followthe advice in these. Some of the main points forcarers are given in chapter 5.

35 Children under 5 should never be left alonewhile they are eating, in case they choke.

See also Food hygiene and safety issues for infantson page 13.

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Organisation of mealtimes and snacks

36 Breakfast is a particularly important meal andfortified breakfast cereals can make an importantcontribution to daily vitamin and mineralintakes. Parents and guardians should worktogether with carers to ensure that children havebreakfast, either at home or in child care.

37 Children need to eat regularly and it isrecommended that the timing of meals andsnacks is organised with the aim of ensuringthat children eat regularly.

38 Children need nutritious snacks between meals.The best snacks are those which are low inadded sugar. A variety of snacks should beoffered including fruit, vegetables, milk, yoghurt,any type of bread, and sandwiches with savouryfillings.

Sustainability

39 Food purchasers should consider theenvironmental impact of their food and drinkchoices and where possible buy local food inseason and food from sustainable sources.

Creating the right atmosphere and encouraging social skills

40 Meals can be times of pleasant social sharing. Itis good practice for carers to sit with childrenduring meals and snacks. It is important thatwhat the carer eats and drinks provides a goodrole model for healthy eating.

41 Mealtimes offer an opportunity to extendchildren’s social and language skills. Childrencan learn from the carer about table manners,and can practise their speaking and listeningskills. To encourage this, distractions such astelevision are best avoided during mealtimes.

42 Children aged 2-4 years should be allowed toserve themselves during meals as this mayencourage them to try different kinds of foods.Finger foods of all kinds, particularly fruit andvegetables, will encourage children under 2years of age to feed themselves and try newfoods. Child-sized utensils, crockery, tables andchairs may also make it easier for children toserve themselves and learn to eatindependently.

43 Children should be allowed to make their ownfood choices. If a child refuses a food or meal,the carer should gently encourage them to eat,but children should never be forced to eat. Tominimise food refusal, it is important to ensurethat a variety of foods are offered.

44 Some children may eat slowly. It is important toensure that all children have enough time to eat.

Learning through food

45 Food can be used in a variety of educationalways, for example to teach children about foodsources, nutrition, health, the seasons, growingcycles and other people’s ways of life. Learninghow to choose and enjoy many differentnutritious foods in early childhood can providethe foundation for a lifetime of wise foodchoices.

46 Carers should involve children in preparing foodand laying and clearing tables.

47 Holidays, festivals and religious occasionsprovide a valuable opportunity for children tolearn about different cultures and special eventsand the variety of foods associated with theseevents.

Involving and listening to parents and guardians

48 A real partnership between parents or guardiansand carers should be fostered. This couldinclude:• making menus available to parents, and• giving parents adequate notice of any changes

to meals, food choice or any other aspect offood provision, and allowing them tocomment on and discuss the changes beforethey are introduced.

49 Carers should give parents or guardians clearinformation each day about what food has beeneaten and if their child has eaten well. Evenolder children may not be accurate in reportingwhat they have eaten.

50 Carers should ask parents or guardians aboutany special dietary requirements their child hasbefore the child starts attending the childcaresetting. Parents of children who are on specialdiets (for example a gluten-free diet), or whohave food allergies are responsible for providing

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the carer with information about the foodchoices available to their child, and parents andcarers should jointly prepare a dietarymanagement plan.

51 Carers should seek advice from parents andguardians if they are serving food which thecarers themselves are not familiar with. Suchfood should not only contain the rightingredients but should look and taste right too.

52 Carers may wish to remind parents of theimportance of giving vitamin drops to under-5s.Vitamin drops containing vitamins A, C and Dare available free to children up to 5 years oldin certain low-income families. Parents can getmore information from their health visitor or GP,or from www.healthystart.nhs.uk.

Equal opportunities

53 All children, and their parents or guardians,should be respected as individuals, and theirfood preferences and religious requirementsshould be accommodated.

54 When planning food provision and menus,carers need to consider children who havespecial needs. Some children may haveparticular dietary requirements or may needspecific help with eating, both of which areoutside the scope of this report. Parents orguardians and carers may find it useful tocontact support groups associated with thechild’s particular disability or need.

55 Carers should positively encourage both boysand girls to participate in all activities, includingfood-related activities such as cooking.

56 All that children bring with them to their placeof child care – their race, gender, familybackground, language, culture and religion –should be valued in order for children to feelaccepted and accepting of themselves. It istherefore important to value the contributionswhich different cultures and nationalities maketo the variety of foods eaten in the UK today.

Infants (children under 12 months)

The Expert Working Group recognises that manyinfants under the age of 12 months enter child care.Guidelines on infant nutrition are given in chapter 4and are summarised here.

Drinks

1 Breast milk is the best food for infants. Carersshould support breastfeeding mothers andencourage them to continue providing breastmilk. Mothers who are breastfeeding and whomay wish to feed their baby in the childcaresetting should have warm, private facilities madeavailable to them.

2 If expressed breast milk is not provided, infantsshould be given an appropriate infant formula.

3 Babies who are bottle-fed should be held andhave warm physical contact with an attentiveadult while being fed. Wherever possible, babiesshould be fed by the same person at each feedwhile in child care.

4 Babies should never be left propped up withbottles as this is both dangerous andinappropriate to babies’ emotional needs.

5 From 6 months of age, infants should beintroduced to drinking from a cup or beaker,and from the age of 12 months, they should bediscouraged from drinking from a bottle.

6 Cow’s milk is not suitable as a main drink forinfants under 12 months. However, whole cow’smilk can be used as an ingredient in weaningfoods – for example to moisten mashed potato.

7 If drinks other than milk or water are given – forexample baby juices or baby drinks – theseshould be diluted with at least 10 parts waterand should be confined to mealtimes. Becauseof the risk to dental health, children over 6months should not be given these drinks in afeeding bottle. Water given to children under 6months should be boiled and cooled first.

8 Adult-type soft drinks or ‘diet’ drinks, tea andcoffee are not recommended for infants.

See also Dental health on page 10.

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Weaning (from 6 months)

9 Infants under 6 months should not be given thefollowing foods: foods containing gluten (suchas bread, pasta or chapatis); nuts and seeds(including peanuts, peanut butter and other nutspreads); eggs; raw or cooked shellfish, shark,swordfish and marlin; citrus fruit and citrusjuices; foods containing plant sterols; or honey.

10 Salt should not be added to foods for infants.

11 Naturally sweet fruits (such as apples orbananas) can be used to sweeten foods ratherthan adding sugar.

12 Artificial sweeteners should not be added tofoods for infants.

13 Soft cooked meat, fish and pulses (for examplepeas, beans and lentils) are important foods toinclude in the diet from 6 months.

14 It is important to offer a variety of flavours andsoft textures. Between 6 and 12 months, foodshould be given which allows the infant to learnto chew and accept a wide variety of foodtextures.

15 If using commercial weaning foods, follow themanufacturer’s instructions carefully.

16 Eggs given to babies or toddlers should becooked until both the yolk and the white aresolid.

17 Because children in the first year of life arefollowing individual feeding and sleepingpatterns, it is recommended that these are notdisrupted but wherever possible integrated intothe carer’s timetable for the day.

18 It is recommended that children up to the age of5 years should receive vitamin drops containingvitamins A, C and D. This is the responsibility ofthe parents or guardians but carers couldprovide information about where to find outmore about them.

Food hygiene and safety issues for infants

19 Expressed breast milk provided for babies inchild care should be clearly labelled with thechild’s name and the date, stored in arefrigerator and only used for that child. Anyexpressed milk left over at the end of the dayshould be returned to the parent or guardian.

20 Wherever possible, formula milk feeds shouldbe made up fresh for each feed, using boiledwater that is hotter than 70oC. (This means waterthat has been boiled and left to cool for about30 minutes.)

21 If the carer is making up infant formula, it ispreferable if it can be made in a separate milkpreparation area.

22 If at any time bottles of milk or infant formulaare heated, a microwave should not be used asthe contents can become very hot even thoughthe container still feels only warm.

23 Bottles and teats for infants under 6 months ofage should be thoroughly cleaned and sterilised.The teats of bottles for older infants should bethoroughly cleaned.

24 If dummies or comforters are used, they shouldbe thoroughly cleaned and sterilised for infantsunder 6 months, and thoroughly cleaned forolder infants. These recommendations alsoapply to dummies or comforters which aredropped.

25 If the carer is serving food from a can or jar andthe child is unlikely to eat all the contents, aportion should be spooned into a separate dishor container before serving it to the child. Anyunused portions should be stored according tothe manufacturer’s instructions. (If there are noinstructions, the safest option is to throw theunused portion away.) If food is served straightfrom the jar and the child does not finish it, theremainder should be thrown away.

26 Any uneaten food which parents have broughtin should be returned to them at the end of theday.

See also Food hygiene and safety issues on page 10.

References

1 Gregory JR, Collins DL, Davies PSW, Hughes JM, Clarke PC. 1995. NationalDiet and Nutrition Survey: Children Aged 11/2 to 41/2 Years. Volume 1:Report of the Diet and Nutrition Survey. London: HMSO.

2 Shaw NJ, Pal BR. 2002. Vitamin D deficiency in UK Asian families:activating a new concern. Archives of Disease in Childhood; 86: 147-149.

3 Ofsted. 2006. Quarterly Childcare Statistics. 31 December 2005.Accessed fromwww.ofsted.gov.uk/publications/index.cfm?fuseaction=pubs.displayfile&id=4148&type=pdf

4 Crawley H. 2006. Eating Well for Under-5s in Child Care: TrainingMaterials for People Working with Under-5s in Child Care. London:Caroline Walker Trust.

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Chapter 2 Why nutritional guidelines are needed

Healthy eating and physical activity are essential forgrowth and development in childhood. To helpchildren develop healthy eating patterns from anearly age, it is important that the food and eatingpatterns to which they are exposed – both at homeand outside the home – are those which promotegood health and positive attitudes to goodnutrition. This chapter describes the current diet ofunder-5s and food provision for under-5s in childcare, and explains why nutritional guidelines areneeded.

The diet of under-5sin Britain

Growing children need plenty ofenergy and other nutrients toensure they grow and developnormally. A good appetite willusually make sure they getenough energy from the foodthey eat, but there is evidencethat children under 5 in Britainare consuming diets higher in thetype of sugar that damages teeththan is currently recommended.1

In addition, the intakes of somevitamins and minerals have beenfound to be lower than the levelswhich are likely to fulfil thenutrient needs of most children.Intakes of vitamin A, vitamin C,iron and zinc in particular havebeen found to be low among aconsiderable proportion ofchildren under 5.1 Intakes ofmeat, fish, vegetables and fruitare generally low. Increasingintakes of these foods would helpto ensure that children have theright amounts of vitamins andminerals for adequate growth anddevelopment.

Under-5s in child care

The number of children underthe age of 5 spending some timebeing cared for outside the familyhome has risen substantially as anincreasing number of mothers ofyoung children return to theworkforce. There are about 3 million children in the UKbelow compulsory school ageand many of these children arecared for in a number ofchildcare settings including daynurseries, nursery schools,playgroups, with childminders,and in crèches, with au pairs,private nannies, relatives andfriends. In addition some under-5s are in early education in bothnursery classes and receptionclasses. The mix of provision ofchild care has changedsubstantially in recent years with

I play footballImogen, aged 4

15


providers in the public, privateand voluntary sectors respondingto government initiatives toincrease the number of childcareplaces available through theNational Childcare Strategy. Since1997 parents have been givenfinancial support for child carethrough the Childcare Tax Creditand the childcare element of theWorking Tax Credit and currentlymore than 55% of the totalchildcare costs are paid for byGovernment and privatecompanies and 45% – over £3,000million a year – by privateindividuals.2

Child care in England,20053

Childminders

Registered childminders 71,500Number of places 321,200

Full-day care*

Number of providers 12,900Number of places 553,100

Sessional day care**


Out-of-school day care


Crèche day care


Early education and primaryschools4

Number of places for 3 year olds 538,800

Number of places for 4 year olds 577,300

* Full-day care facilities provide day care forchildren under 8 for a session which is acontinuous period of 4 hours or more. Thisincludes day nurseries, children’s centres andsome family centres.

** Sessional day care provides care for childrenunder 8 for a session which is less than acontinuous period of 4 hours in any day, where children attend for no more than fivesessions a week.

Data from Ofsted on registeredchildcare providers and placesshowed that over 1.5 millionplaces were available in Englandin 2005 (see Child care inEngland, 2005, below). Thelargest childcare providers arethose offering full-day care andsessional day care (periods of lessthan 4 hours of continuous care).There has been an increase in thenumber of private sector daynurseries and a decrease inchildminder places since 1997.2

In Scotland in 2005 there were263,000 pre-school age childrenserved by 6,100 childminders and4,717 childcare and pre-schooleducation centres of which 711were private nurseries.5 In Walesin 2005 it was reported that therewere 72,856 registered childcareplaces for under-8s, 15% of themprovided by childminders.6 InNorthern Ireland, 9,197 places forunder-5s were registered with daynurseries and 18,065 places withchildminders in 2005.7

The type of child care used byparents or guardians of theunder-5s depends on what isavailable and what they canafford, and may change as thechild gets older. Parents maychoose nursery schools or pre-school playgroups to socialiseand stimulate their childrenbefore schooling begins, ratherthan primarily as a form of childcare. In many cases there is acombination of these forms ofcare: for example, a childmindermay look after a child duringparental working hours when thechild is not at nursery school orplaygroup.

It is estimated that there areapproximately 350,000 peopleworking in the early yearsworkforce.8 The cost of child carehas increased substantially in thelast few years with the averagecost of a full-time nursery placein England for a child under 2 in2005 being £141 per week,although costs are very variedacross the country.9

Food provision inchild care

Although parents or guardianshave the main responsibility forproviding adequate andappropriate food for theirchildren, day care providerssupply an increasing proportionof the total food eaten bychildren in their care. There is alack of published work on foodprovision in the UK under-5s daycare sector. The current evidenceavailable suggests that there is awide variation in the quality andquantity of food provision inchildcare settings but there isincreasing evidence of goodpractice.

In 2006 Ofsted carried out asurvey into food served in 110childcare settings: 64 childmindersand 46 day-care providers.10 Theinspectors judged that themajority of providers offered ahealthy and balanced diet forchildren but some weakerproviders were also identified.Particular concerns in somesettings were infrequent servingof fruit and vegetables, lack ofvariety in snacks served, offeringsweets as rewards, and the lackof integration of food served withdiscussions about healthy eating.

A survey published in 2005carried out among 168 childcareproviders in West Yorkshire11

found that only half of nurseriesand a quarter of childmindersoffered fruit and vegetables atmain meals every day. In thisstudy only 14% of nurseries and21% of childminders offeredcalcium-rich foods at main meals,and about half provided meatevery day. While childcareproviders in this study sawthemselves as responsible forpromoting a healthy diet, manyhad had no training in eating welland current guidance wasperceived as vague. This studyalso highlighted tensions between

16


successful approach to foodintake requires that thoseproviding child care have acommitment to good practice aswell as an appropriate nutritionpolicy. In 2003 the report EveryChild Matters17 saw a new focuson quality services for children inthe UK. In 2004 a 10-year strategyfor child care was announcedwhich aims to work towardsnational provision of the highestquality child care in the world.18

The Caroline Walker Trust wouldlike to see the right of every childto good food to be a significantpart of this new vision.

that further support, guidanceand training are needed for theinspectorate, and for early yearsworkers, to help them interpretwhat ‘healthy and nutritious’meals and snacks means inpractice. Nutritional Guidance forEarly Years,14 published inScotland in 2006, providespractical support to all thoseworking in the sector to meet theScottish National Care Standards.The Caroline Walker Trust hopesthat this Eating Well for Under-5sin Child Care report will offeradditional information toproviders across the UK and thatboth this report and the trainingmaterials15 which accompany itwill be the basis of guidance inthis sector for England, Wales andNorthern Ireland.

Across Europe, nutritionalstandards for food provided innurseries, kindergartens and othernon-school settings are used inAustria, Denmark, France, Italyand some parts of Belgium andare followed by most localauthorities in Sweden.16 In Italy allchildren in child care eat foodthat has been prepared on thepremises by trained staff andcooked to nutritional standardsset by the health ministry. Staffeat with the children, who areallowed to be involved in foodpreparation, and there are stronglinks between food activities andfood provision. Parents areconsulted about menus and paythe equivalent of about £2 for ameal through their nursery fees.In many parts of Europe it is wellaccepted that children learn abouta healthy way of life throughdaily practice and pleasant eatingexperiences.

Those who provide child care for the under-5s are in a uniqueposition to have a positiveinfluence not only on thenutritional intake of those childrenbut also on the knowledge andattitudes children have towardsfood and a healthy lifestyle. A

some childcare providers andparents on issues around foodand concluded that all nurserystaff and childminders shouldhave access to carefully designedadvice on nutritionallyappropriate food and drinkservices for under-5s that theycould also share with parents.

A study in Dundee looking atfood provision in nursery schoolclasses, child and family centresand independent providers12

concluded that the food served tochildren in full-day care providedonly about 50% of their energyneeds and was low in vitamin Cand iron. Data from the ALSPACsurvey in Bristol on the food andnutrient intakes of 3 year olds13

reported that, when the nutrientintakes of meals provided byparents and meals provided byother carers were compared,there were little nutritionaldifferences, suggesting that foodin child care often mirrors thatoffered in the home and istherefore likely to contribute tothe higher than recommendedintakes of sugars and lowerintakes of fruit and vegetablesobserved.

Since the first edition of EatingWell for Under-5s in Child Carewas published in 1998, newstandards have been introducedfor children in full-day child care,sessional child care, crèches, out-of-school care, and withchildminders. These standards areused by those inspectingchildcare facilities through theappropriate regional agencies ofthe UK. The standards forEngland published in 2001 aresummarised in Appendix 1.National Care Standards forScotland published in 2002 canbe found at www.scotland.gov.uk/library5/education/ncsee.pdf.National Care Standards for Walespublished in 2000 can be foundat www.csiw.wales.gov.uk. TheCaroline Walker Trust welcomesthese new standards but believes

The Caroline Walker

Trust believes that

every child has the

right to good food, and

that this should be part

of the vision for high

quality childcare

services in the future.

17


Aims of this report

In 1998 the Caroline Walker Trustidentified a need for clear,practical and nutritionalguidelines for food provided forunder-5s in child care. With thefinancial support of theDepartment of Health, the Trustbrought together an ExpertWorking Group to produce thefirst edition of this report. A list ofMembers of the Group is givenon page 2. This second editionupdates the information providedin the 1998 report and extendsthe nutrient-based standards toreflect new recommendationsmade since 1998 as well as toreflect new evidence on thenutritional needs of under-5s.

The aims of this report are:

• To provide clear, referencedbackground information aboutthe relationship between goodnutrition and health anddevelopment among infantsand children under 5.

• To provide practical guidelinesto enable local authorities,caterers, nursery owners andmanagers, childminders,cooks/chefs and othersresponsible for providing foodfor infants and under-5s inchild care and other early yearssettings, to develop suitablemenus which achieve a goodnutritional balance and variety.

• To act as a resource documentfor those working for betterstandards of nutrition for infantsand under-5s in child care andother early years settings.

This report deals with children upto their fifth birthday. The terminfants applies to children up to12 months. The term under-5sapplies to 1-4 year olds – ie.children from the age of 12months up to their fifth birthday.The term carers applies to staffworking in child care and earlyyears settings including localauthority and private nurseries,and childminders.

Who the report is for

The main audiences for thereport are:

• Those agencies who contract,register, monitor and inspectnurseries, childminders andother childcare and early yearssettings (the Early YearsDirectorate of Ofsted; theScottish Commission for theRegulation of Care [CareCommission] and Her Majesty’sInspectorate of Education[HMIe]; Department ofEducation Northern IrelandInspection Services; and Estyn,the office of Her Majesty’s ChiefInspector of Education andTraining in Wales).

• Directors of Education andDirectors of Children’s Servicesand Children and YoungPeople’s Strategic Partnerships

• Children’s Trusts and Centres,and Healthy Start and Sure Startteams

• Owners, managers, cateringstaff, local authority staff,childminders, teachers andother carers in environmentsproviding child care for infantsand under-5s

• Parents and guardians ofinfants and children under 5who will be using childcarefacilities outside their ownhomes

• MPs, MSPs, MEPs (Members ofthe European Parliament), civilservants, writers and journalistswho may wish to know moreabout aspects of the nutritionalneeds of infants and under-5sin child care.

The provision of food to infantsand under-5s is crucial tochildren’s health and wellbeing.The Caroline Walker Trust hopesthat the nutrient-based standardscontained in this report becomeaccepted standards andrecommends that all thoseinvolved in the care of infantsand under-5s should adopt all thenutritional guidelines outlinedhere and put the recommend-ations into practice.

18


References

1 Gregory JR, Collins DL, Davies PSW, HughesJM, Clarke PC. 1995. National Diet andNutrition Survey: Children Aged 11/2 to 41/2

Years. Volume 1. Report of the Diet andNutrition Survey. London: HMSO.

2 National Audit Office. 2004. Early Years:Progress in Developing High Quality Childcareand Early Education Accessible to All. London:TSO.

3 Ofsted. 2006. Quarterly Childcare Statistics.31 December 2005. Accessed fromwww.ofsted.gov.uk/publications/index.cfm?fuseaction=pubs.displayfile&id=4148&type=pdf

4 Department for Education and Skills. 2006.Provision for Children Under 5 Years of Age inEngland: January 2006 (provisional). Accessedfrom www.dfes.gov.uk/rsgateway/DB/SFR/

5 Scottish Executive. 2005. Pre-school andChildcare Statistics 2005. Accessed fromwww.scotland.gov.uk

6 Care Standards Inspectorate for Wales. 2005.CSIW Annual Report 2004-2005. Accessedfrom www.csiw.wales.gov.uk

7 Information on childcare places in NorthernIreland for the year ending 31st March 2005,accessed fromwww.publications.parliament.uk/pa/cm200506/cmhansrd/cm060306/text/60306w14.htm

8 Cameron C. 2004. Building an IntegratedWorkforce for a Long-term Vision of UniversalEarly Education and Care. London: DaycareTrust.

9 Daycare Trust. 2005. Childcare Costs Survey.Accessed from www.daycaretrust.org.uk

10 Ofsted. 2006. Food for Thought: A Survey ofHealthy Eating in Registered Childcare.Accessed from www.ofsted.gov.uk

11 Moore H, Nelson P, Marshall J, Cooper M,Zambas H, et al. 2005. Laying foundations forhealth: food provision for under 5’s in daycare. Appetite; 44: 207-213.

12 Wrieden WL, Farley K, Anderson AS. 2001.Food in Early Years. An Audit of FoodProvision in Nursery School and Classes, Childand Family Centres and Independent SectorPartner Providers in Dundee. Final Report toTayside Health Board. Dundee: NinewellsHospital Medical School.

13 Emmett P, Rogers I, Symes C and the ALSPACStudy Team. 2001. Food and nutrient intakesof a population sample of children in theSouth West of England in 1996. Public HealthNutrition; 5: 55-64.

14 Scottish Executive. 2006. NutritionalGuidance for Early Years. Edinburgh: ScottishExecutive.

15 Crawley H. 2006. Eating Well for Under-5s inChild Care: Training Materials for PeopleWorking with Under 5s in Child Care. London:Caroline Walker Trust.

16 Children in Europe. 2006. An Appetite forLife: Young Children, Food and Eating.Accessed from www.childrenineurope.org

17 HM Treasury. 2003. Every Child Matters.London: HM Treasury.

18 HM Treasury. 2004. Choice for Parents, TheBest Start for Children: A Ten Year Strategyfor Childcare. London: HM Treasury.

19

Chapter 3 Nutrition and 1-4 year olds

This chapter provides the basic nutrition informationneeded to understand the nutrient-based standardsfor under-5s in child care given in chapter 6 of thisreport. It looks at energy (calories), protein, fat,carbohydrates, fibre and some of the importantvitamins and minerals needed by the under-5s. Itoutlines why they are needed, how much childrenneed, and whether they are getting enough or toomuch based on current scientific evidence.

My favourite lunch in spaceMustafa, aged 41/2

The following information appliesto 1-4 year olds (ie. children fromthe age of 12 months up to theirfifth birthday), unless otherwisespecified. Information on infantsup to the age of 12 months isgiven in chapter 4.

Nutrient-based standards areexpressed in terms of theamounts (both maximum andminimum) of individual nutrientsneeded for good health. Mostfoods contain a number ofdifferent nutrients so it is thebalance of different foods withina person's eating pattern whichdetermines whether therecommendations for ‘healthyeating’ are met, rather thanwhether a person is eatingparticular foods. It is importantthat children are given varieddiets if they are to obtain all thenutrients their bodies need. Howchildren can achieve the balanceof nutrients they need from thefood they eat is considered inchapter 5.

20

Energy (calories)

Why children need energy

Children need a certain amount of energy(calories) to enable them to function and beactive. The body gets energy from fat,carbohydrate and protein (and in adults fromalcohol), but most energy needs are met by fatand carbohydrate.

Children also need energy (calories) for growthand development. This is particularly important inchildren up to the age of 5 years as this is a timeof rapid growth in muscles and bone tissues andin the development of the brain.

Energy is measured in kilocalories (kcals), whichis a metric term for calories. It can also beexpressed in kiloJoules (kJ). 1kcal equalsapproximately 4.2kJ.

How much energy do children need? Wheredo they get their energy (calories) from?

The energy needs of each individual are different,and recommendations for a healthy diet are oftenexpressed as what proportion of energy shouldcome from fat and carbohydrate (see Fat on thenext page and Carbohydrates on page 22). Theaverage amount of energy that a group ofchildren of different ages from 1 year up to 4years are likely to need are summarised below.(These are average figures for boys and girls: amore detailed breakdown of energy requirementsby age and gender is given in Appendix 3.)

Age Average energy requirements in kcals (calories) per day 1

1 year 935kcals2 years 1,160kcals3 years 1,430kcals4 years 1,530kcals

The nutrients fat, carbohydrate and protein allprovide the body with calories. (For more aboutthese nutrients see pages 21-24.) At present,under-5s in the UK get most of their energy fromcarbohydrates (about 51%) and fats (about 36%),with protein providing about 13%.2

The proportion of energy that under-5s currentlyget from carbohydrate and fat meets therecommendations. However, more of the energyfrom carbohydrates should be provided by cerealfoods, vegetables and potatoes, and less fromconfectionery and soft drinks as these foods arehigh in sugar but provide few other nutrients.

It is important to note that children do not needsugar for energy. (For more information aboutsugar and other carbohydrates, see pages 22-23.)

The increase in childhood obesity in the UK hasbeen well documented and approximately 30% ofboys and 28% of girls aged 2-10 years areoverweight or obese.3 Obesity in children isdifficult to treat as care must be taken to maintaingrowth and development. Overweight childrenshould be encouraged to increase their activity.More information on physical activity can befound opposite and on page 46.

The importance of physical activity forthe under-5s

The energy we need every day is determined bothby a basic level of requirement to keep our bodiesfunctioning (called the Basal Metabolic Rate or BMR)and by the amount of physical activity that we do(for example moving around, walking, orexercising). People who are inactive have lowerenergy needs and will eat less food to maintaintheir body weight. It becomes much harder to getall the nutrients needed for good health if less foodis eaten.

Physical activity is essential for optimal growth anddevelopment in children. It is generally agreed thatchildren now are less active than those in previousgenerations. This has been caused by a number offactors including, for example, the time spentwatching television, with recent evidencesuggesting that among 3-4 year olds TV viewing ispositively associated with higher body weight:those spending longer periods of time watching TVtend to have a higher body weight.4 A study ofchildren in Glasgow suggests that children aredeveloping sedentary lifestyles from a very earlyage, with 3 year olds and 5 year olds spending 79%and 76% of their time in sedentary behavioursrespectively.5 The Health Survey for England (2002)6

and the Scottish Health Survey (2003)7 suggest thatabout a third of under-5s do not take part in 60minutes of moderate activity every day. Restrictionson children being able to walk to school or playfreely outside, for safety reasons, contribute to this.8


21


Fat

Fat in the diet

Fat provides the most concentrated form ofenergy in the diet.

There are basically two types of fat: saturated fats,which are mainly from animal sources; andunsaturated fats, which are found mainly in plantsand fish. The unsaturated fats include a groupcalled polyunsaturated fats.

Some fat in the diet is essential and thedeveloping child has a particular need for whatare known as ‘essential fatty acids’. These areimportant for healthy development. Breast milk isrelatively high in essential fatty acids to reflect thisneed. Fat in foods also provides some of the fat-soluble vitamins – vitamins A, D and E (seepage 26).

How much fat should there be in children’sdiets? Are children getting too much?

Healthy eating recommendations for people agedover 5 are that total fat should provide no morethan 35% of total food energy and that saturatedfat should provide no more than 11% of foodenergy.1 Between infancy and 5 years there is anexpectation that the proportion of energy derivedfrom fat will fall from 50% (as supplied bybreastfeeding) to 35% (as recommended foradults).

There is discussion about whether therecommendations for the proportion of fat in thediet intended for everyone over 5 years of age(which are designed to reduce heart disease inthe population) should also be applied to childrenunder 5. The prevailing view is one of cautionbecause there is concern that very low fat intakesmay have an adverse impact on children’s growthand development. There is also concern thatchildren – who require a relatively nutrient-densediet – may not get enough energy and nutrients ifthey are given low-fat foods. For example, it isrecommended that children under the age of 2years are given whole milk and that skimmedmilk is not given before 5 years of age.9 The term‘muesli belt malnutrition’ was coined to describechildren from relatively affluent households whofailed to grow and develop normally when givendiets inappropriately low in fat.

However, evidence from a large longitudinal studyof children at 18 months suggests that there is no

evidence that children who have fat intakesproviding 30-35% of energy experience delayedgrowth and there is in fact evidence that childrenon higher fat diets (where 39-43% of energy isfrom fat) may have lower intakes of iron andvitamin C and lower iron status.10 It was alsoreported that higher fat intakes were associatedwith higher total cholesterol levels among boyseven at this young age, and this again maysuggest that ensuring fat intakes are moderateamong under-5s may be beneficial for futurehealth.

Children between the ages of 1 and 4 years inBritain currently appear to get about 35% of theirenergy from fat2 and maintaining this level of totalfat intake is to be encouraged as children getolder.

The intake of saturated fat among those aged 1-4years is about 16% of food energy.2 Although thisis higher than the 11% recommended for peopleaged 5 years and over, this is to be expectedsince milk consumption in this group is high:almost a third of the saturated fat in the diets ofunder-5s is provided by milk.

n-3 polyunsaturated fats (omega-3 fats)

Long chain n-3 polyunsaturated fatty acids (alsoknown as omega-3 fats) are derived primarily fromoil-rich fish. The importance of omega-3 fats hasbeen established for brain development in babiesprenatally (in the womb)11 and probably in earlypostnatal life and these fats are thought to bebeneficial for heart health in adults.12 There is,however, insubstantial evidence that supplementsof omega-3 fats are beneficial for health inchildren or that they improve learning orconcentration. (See Diet, behaviour and learningin children on page 53.)

The most significant natural food source ofomega-3 fats is oil-rich fish such as salmon, trout,sprats, herring, mackerel, sardines, pilchards andfresh tuna. (Other n-3 polyunsaturated fats can befound in oils such as rapeseed oil and soya oil;walnuts and almonds; pumpkin seeds; organicmilk; and green leafy vegetables such as broccoliand spinach. However, there is no evidence thatthese n-3 polyunsaturated fatty acids protectagainst heart disease.)

22


Carbohydrates

Starch, intrinsic sugars and milk sugars

Carbohydrates is the term used to describeboth starch and sugars in foods. Carbohydratesprovide energy.

Starch is the major component of cereals,pulses, grains and root vegetables. Most peoplecan visualise starchy foods when they think offlour and potato.

The term ‘sugars’ is often assumed to describesomething white and granular found in sugarbowls, but in fact the sugars found in foodscan be quite variable. In order to clarify theroles of different sugars in health, the sugars infoods have been distinguished as: intrinsicsugars, milk sugars and non-milk extrinsicsugars (or NME sugars). Intrinsic sugars andmilk sugars are the sugars found naturally infoods such as milk, vegetables and fruits. NMEsugars include table sugar, sugar added torecipes, and honey. NME sugars are also foundin foods such as confectionery, cakes, biscuits,sugary breakfast cereals, soft drinks and fruitjuices.

It is recommended that, for the population as awhole, carbohydrates should provide about50% of total food energy, and that most of thisshould come from starch, intrinsic sugars, andsugars found naturally in milk, and that 11% orless energy should be provided by sugarswhich have been primarily added to otherfoods.1 Children do not need ‘sugars’ forenergy. They can get all the energy they needfrom other carbohydrate foods. Although thecurrent recommendations for intakes of sugarswere designed for everyone over the age of 5,there is no evidence to suggest that childrenunder 5 require diets that are higher in non-milk extrinsic sugars. Recent advice in Scotlandrecommends that non-milk extrinsic sugars

How much do children need? Are they gettingenough?

It is currently recommended that starch, intrinsicsugars and milk sugars together should provideabout 40% of energy to the diet by the age of 5years.1 Starch, intrinsic sugars and milk sugarscurrently provide about 32% of all energy in thediets of 1-4 year olds in Britain, and 10% of this isprovided by milk sugars.2 As milk intakes declineand appetites increase it is recommended that foodssuch as bread, potatoes, pasta and rice replace theenergy no longer provided by milk. Starchy foodssuch as these fill children up, are a good source ofenergy and can also provide important nutrientssuch as fibre and some of the B vitamins.

Younger children who have smaller appetites mayfind starchy foods very filling, and a balance isrequired between the energy provided by starchyfoods and that from other foods such as, forexample, meat and milk (and products containingmeat or milk) which may provide energy with lessbulk.

Sources of starch and intrinsic and milk sugars

Sources of starchSources of starch include bread, rice, chapatis,pasta, couscous, breakfast cereals, potatoes, yamsand plantains. Whole grain cereals are a valuablesource of fibre (see page 25) but can be bulky and

C ARBOHYDR ATES

SUGARSSTARCH

Non-milk extrinsic sugars (NME sugars)

Intrinsic sugars Milk sugarsStarch is the main componentof cereals, pulses, grains androot vegetables.

These sugars are found naturally in foods such asvegetables, fruits and milk.

This includes table sugar,sugar added to recipes,and sugars in soft drinks.

provide no more than 11% of food energy forchildren aged 1-5 years13 and the Caroline WalkerTrust supports this recommendation.

23


Non-milk extrinsic sugars (NME sugars)

What are non-milk extrinsic sugars?

In the past, sugars were often referred to as ‘addedsugars’ and ‘natural sugars’ – terms which manypeople found confusing. The Government’sadvisory panel COMA (Committee on MedicalAspects of Food and Nutrition Policy) defineddifferent sugars in the diet more preciselydepending on their effects on health. ‘Non-milkextrinsic sugars’ – or NME sugars – are those whichhave been extracted from a root, stem or fruit of aplant and are no longer incorporated into thecellular structure of food. NME sugars thereforeinclude table sugar, sugar added to recipes, andsugars found in soft drinks and fruit juices. Honeyis also included in this group.

The development of tooth decay is positivelyrelated to the amount and particularly the frequencyof NME sugars in the diet.14 This is most markedwhen sugar is eaten both at and between meals.

Sources of NME sugars

Sources of NME sugars include soft drinks, fruitjuice, sweets, chocolate, cakes, biscuits, sugarybreakfast cereals, table sugar and honey.

How much are children getting? Are theygetting too much?

The recommendation to reduce the energy in thediet provided by NME sugars is primarily to preventtooth decay.1 The other concern is that foods highin NME sugars often provide calories but few othernutrients. This is particularly true for drinks such assquashes and fizzy drinks, sweets, and sugar addedto drinks and cereals. Children need a relativelynutrient-dense diet. If a large proportion of thefoods and drinks they consume are high in NMEsugars, it may be difficult for under-5s to obtain allthe nutrients they need each day.

The intakes of NME sugars among pre-schoolchildren in Britain are currently significantlyhigher than recommended. According to anational survey, children aged between 1 and 4years in Britain obtain about 20% of their energyfrom NME sugars,2 which is about twice thecurrent recommendation. (The contribution ofNME sugars to the diet should be no more than11% of total food energy.) About 10% of thechildren in this survey were getting a third ormore of their energy from NME sugars alone.

It is important to protect the first (milk) teeth ofpre-school children so that these teeth stay inposition to allow for the normal development ofthe permanent teeth. Pre-school children areconsidered at high risk for the development oftooth decay.9

When intakes of NME sugars are compared withdental health it has been shown that theconsumption of sugary drinks at bedtime andfrequent consumption of sugar confectionery andnon-diet soft drinks are related to the amount oftooth decay.15 For example, 40% of 3-4 year oldswho had sugar confectionery most days, or moreoften, had experience of tooth decay, comparedwith 22% of those who had sugar confectioneryless frequently.

It has also been reported that decay is more likelyto affect pre-school children who are given firstweaning foods containing sugar, those stilldrinking from a bottle at 2 years of age, and thosewho are given sweetened comforters (mostcommonly a sweet drink in a bottle or, lessfrequently, a dummy dipped in honey or jam).16 Itis therefore important not only to reduce theamount of NME sugars but also to reduce thefrequency and the amount of contact that sugaryfoods and drinks have with the teeth.

The main sources of NME sugars among theunder-5s are soft drinks (which contribute about athird of NME sugars), cereals and cereal products,and confectionery (which contribute about aquarter of NME sugars each) and table sugar itselfwhich contributes about 5%.2 Reducing the intakeof soft drinks would have a major impact on theamount of NME sugars in many children’s diets.

For more information about drinks for the under-5s and about dental health and practical ways toreduce tooth decay in the under-5s, see page 50.

should be introduced gradually to the diets ofunder-5s.

Sources of intrinsic and milk sugarsSources of intrinsic and milk sugars include fruits(but not fruit juices – see below) and vegetablesand milk.

24


Protein

Why children need protein

Protein is needed for growth and the maintenanceand repair of body tissues and to make theenzymes that control many body functions.

How much protein do children need? Are theygetting enough?

Protein needs are proportionally higher forchildren than for adults but most children inBritain have more than adequate intakes ofprotein. For example, children aged between 1and 4 have an average intake of 36.4g protein aday and those aged 4-41/2 years an average intakeof 39.4g a day.2 These figures, which are typicalfor Western diets, are above the ReferenceNutrient Intakes for protein of 14.5g a day for 1-3year olds and 19.7g a day for 4-6 year olds.1 (TheReference Nutrient Intake is the amount of anutrient which is likely to meet the requirementsof most children – see opposite.)

Protein is available from both animal and

vegetable foods, so vegetarian children can getenough protein as long as they get a good varietyof foods every day. For more information onvegetarian diets see page 51.

Sources of protein

Sources of protein include: milk, meat, poultry,fish, eggs, cheese, tofu, pulses such as peas,beans and lentils, and cereal foods such as bread,rice and pasta.

In Britain, children under 5 get about a third oftheir protein from milk and milk products, aquarter from cereals and cereal products, andanother quarter from meat and meat products.2

What is a Reference Nutrient Intake?

The Reference Nutrient Intake (RNI) is the amount of anutrient that is likely to meet the requirements ofnearly everybody in a group. If people get more thanthis amount, they will almost certainly be gettingenough. Reference Nutrient Intakes have been set formany nutrients including protein, B vitamins (thiamin,riboflavin and niacin), folate, vitamins C and A,calcium, iron and zinc.

25


Fibre

Why children need fibre

Fibre (or NSP – non-starch polysaccharides)represents those parts of cereal and vegetablefoods which are not broken down in the smallintestine and which are particularly important toprevent constipation and other bowel disorders. Itis also suggested that some components of NSPare important for lowering blood cholesterollevels.


There is little evidence for the effects of dietaryfibre in young children and no recommendationfor NSP intake is made. It would seem sensiblethat children should have proportionally lowerintakes compared to adults, for whom therecommendation is 18g a day. It has beenreported that children aged 11/2-41/2 years have anaverage intake of 6.1g fibre a day.2

Little information is available on normal bowelmovements in pre-school children or its relationto fibre intake. One study reported that childrenwith a higher average daily intake of fibre aremore likely to have more frequent bowelmovements.2

Constipation in children can be related to poorintakes of fibre and fluid, emotional disturbancesand changes in routine.17 Constipation may be

alleviated by a modest increase in fibre-rich food(particularly fortified high-fibre breakfast cereals,wholemeal bread and fruit and vegetables). It isvery important that adequate fluids are drunk iffibre intakes are increased or if children appearconstipated. Raw bran should never be given tothe under-5s as it can cause bloating, wind andloss of appetite and affect the absorption of otherimportant nutrients. If constipation becomestroublesome, medical advice should be sought.

The fears that high-fibre diets in under-5s willlead to growth-faltering and mineral imbalance inthe developed world are not well supported byresearch studies18 and it is suggested that, withrising childhood obesity, increases in fibre mayhelp to reduce energy intake. However, thosechildren under 2 who are fussy eaters should notbe given fibre-rich foods at the expense ofenergy-rich foods which they require for adequategrowth.

Sources of fibre

Sources of fibre include wholemeal bread, wholegrain breakfast cereals, pulses (peas, beans andlentils), and fresh and dried fruit and vegetables.These foods provide useful sources of othernutrients too.

For more information on sources of fibre, seepage 80.

Toddler diarrhoea

Frequent loose stools containing recognisable food matter(such as fruit and vegetable skins, or sweetcorn) is acommon problem in some children who are otherwisehealthy. While this is generally harmless and will improve onits own as the child gets older, excessive fluid intake fromfruit squashes and fruit juices should be discouraged. Clearapple juice contains large quantities of non-absorbablesugars which can make the condition worse.19 Encouraging anormal diet which contains foods from all the food groupsshould be encouraged as some parents may needlesslyrestrict some food items because they believe that theyexacerbate the diarrhoea.

Prebiotics and probiotics

‘Oligosaccharides’ are a component of dietary fibrethat have been shown to have ‘prebiotic effects’. Thismeans that they encourage the growth of lactic acidbacteria, in particular bifidobacteria. These bacteriaare similar to those included in foods and drinkswhich contain probiotics. It has been suggested thatthese bacteria can have a beneficial effect onreducing the incidence of diarrhoea and someallergies (such as eczema) in young children but therehave been insufficient studies to establish whetherthere is any benefit in taking supplements of thesefoods. Including good natural sources ofoligosaccharides such as pulses, fruits and wholegrains in the diet will promote good gut health inyoung children.

26


Fat-soluble vitamins

Vitamin AVitamin D Vitamin EVitamin K

These are stored in the body. Vitamin A in food canbe destroyed by heat or by oxidation if left exposedto the air.

Water-soluble vitamins

B vitamins: thiamin, riboflavin, niacinVitamin B6

Vitamin B12

Folate Vitamin C

These are not stored in the body. They are water-soluble, so they are more likely to be destroyed byheat or by oxidation if left exposed to the air.

Vitamins

Vitamins are often divided into two groups: thosethat are water-soluble and those that are fat-soluble. Some vitamins are found predominantlyor only in animal foods – for example vitamin Dand vitamin B12. Others are found predominantlyor only in foods from vegetable origin, forexample vitamin C.

The fat-soluble vitamins (A, D, E and K) arestored in the body and high doses of vitamins Aand D should not be given.

Water-soluble vitamins (thiamin, riboflavin,niacin, vitamin B6, vitamin B12, folate and vitaminC) are not stored in the body and, because theyare water-soluble, they can leach out intocooking water and are also more likely to bedestroyed if foods containing them are over-cooked or exposed to the air for long periods.

Reference Nutrient Intakes for the under-5s havebeen set for all vitamins except vitamin E andvitamin K. Not enough information is available atpresent to set a Reference Nutrient Intake forthese vitamins.

It is important for children to get enough of eachvitamin. However, having too much does notbring any benefit and may be harmful.

27


Why children need vitamin A

Vitamin A comes in two forms: retinol, which isonly found in animal foods; and carotene, theyellow or orange pigment found in fruit andvegetables (both those coloured yellow or orangeand in many green ones where the orange colour ismasked by chlorophyll pigment). Carotene can beconverted into retinol by the body. It takes 6 unitsof carotene to make 1 unit of retinol.

Vitamin A is often thought of as the ‘anti-infection’vitamin as it plays an important role in maintainingthe immune system. It is also essential for growth,which is why children have a relatively higherrequirement for vitamin A than adults. Vitamin A isalso associated with good vision in dim light asretinol is essential for the substance in the eyewhich allows night vision.

Experts now believe that carotene has a muchwider role than just as a means to produce vitaminA. It may protect the body from internal damagewhich could lead eventually to heart disease or thedevelopment of cancer.


Vitamin A is the most difficult vitamin to get right inthe diets of children, as both deficiency and excesscan be a problem. Children aged 1-3 years have aReference Nutrient Intake (RNI) for vitamin A of 400micrograms a day and those aged 4-6 years of 500micrograms a day1 (see Appendix 3).

A national survey of children aged 11/2-41/2 yearsshowed that almost half of all children had intakesbelow the Reference Nutrient Intake and 8% ofchildren had very low intakes.2 This may be due tothe fact that only a limited number of foods aresources of vitamin A and many children are lowconsumers of vegetables. For this reason, vitamindrops containing vitamin A are recommended for allunder-5s. However, it is important not to give morevitamin drops than recommended because veryhigh intakes of vitamin A can be dangerous. Theycan cause liver and bone damage, hair loss, doublevision, vomiting and headaches.

Vitamin A (also known as retinol equivalents)

It is recommended that regular intakes from foodsources and vitamin drops should not exceed 900 micrograms a day among infants, 1,800 micrograms a day among 1-3 year olds and3,000 micrograms a day among 4-6 year olds.1

A normal diet and appropriate use of vitamindrops (5 drops a day) should give no cause forconcern.

For information on vitamin drops see the nextpage.

Sources of vitamin A

Retinol

Few foods provide retinol naturally. Buttercontains retinol as does cheese and to a lesserextent eggs. Margarine is fortified with vitamin Aby law, and other fat spreads may also be fortifiedin this way. It is worth checking the label of otherfat spreads to see if they are fortified. Milk andmilk products usually provide about a third ofdaily vitamin A intakes in young children.

Liver and liver pâté can contain very high levelsof vitamin A since animals store vitamin A in theirlivers. It is recommended that these foods aregiven to children no more than once a week.20

Carotene

Carrots are the best source of carotene but otherorange foods such as sweet potatoes, mango,melon and apricots (dried or fresh) as well asgreen leafy vegetables (eg. spinach, watercress,broccoli), tomatoes and red peppers are also goodsources.

For more information on sources of vitamin A, seeAppendix 2.

28


Vitamins (continued)

that children up to 5 years of age receivesupplementary vitamin D in vitamin drops.9 (Seebox below.)

There are concerns about the link between theexposure of the skin to UV radiation andsubsequent skin cancer. It is recommended thatchildren should be protected from the sun by usingshade, wearing a sunhat and applying a high factorsunscreen on bare skin.21 Using sunblocks on youngchildren makes the use of vitamin D supplementsespecially important.

Under-5s of Asian origin are more likely to havelower vitamin D status, and a resurgence of ricketshas been reported in many cities in the UK.22 Thismay be due to a number of factors including diet, amore limited exposure to the sun and wearing moreclothing when outside. Vitamin drops areparticularly important for these children.

It is important not to exceed the recommendeddose. High doses of vitamin D can be dangerousand the gap between the requirement and the toxicdose is not large. As little as five times therecommended intake taken regularly is associatedwith symptoms of vitamin D toxicity.

Sources of vitamin D

Very few foods are good sources of vitamin D. Oilyfish such as tuna, salmon and pilchards providevitamin D as do foods fortified by manufacturerssuch as margarine, many fat spreads and breakfastcereals. Infant formula also contains vitamin D. Themain dietary sources of vitamin D among thoseaged 11/2-41/2 years are fat spreads and fortifiedbreakfast cereals.2

For more information on sources of vitamin D, seeAppendix 2.

Vitamin D

Why children need vitamin D

Vitamin D is needed for healthy bones and teeth.Prolonged deficiency of vitamin D in childrenresults in rickets, the main signs of which areskeletal malformation (eg. bowed legs) with bonepain or tenderness and muscle weakness. A childwith vitamin D deficiency is usually miserableand lethargic.


The main source of vitamin D is by exposure ofthe skin to ultraviolet (UV) radiation in summersunlight. Infants and children aged between 6months and 3 years are particularly vulnerable tovitamin D depletion because of their rapid bonegrowth and the limited exposure some may haveto UV radiation. Vitamin D is present in a limitednumber of foods and it is difficult for youngchildren to obtain satisfactory vitamin D intakesfrom diet alone.

After the age of 3 years, people are generally ableto maintain satisfactory vitamin D status fromsunlight if they spend sufficient time outsidebetween April and September. Therecommendation for infants and children agedbetween 7 months and 3 years is 7 micrograms ofvitamin D a day.1 It is recommended however

Vitamin drops

The Department of Health recommends that allchildren up to the age of 5 receive vitaminsupplements (vitamin drops) containing vitamins A,C and D. These vitamins are currently free tochildren up to 5 years old in low-income families(families in receipt of Income Support, income-based Jobseeker’s Allowance or Child Tax Credit [butnot Working Tax Credit] with an income below acertain amount [£14,155 a year in 2006/7]),through the Welfare Food Scheme. This scheme isbeing replaced in phases and will includedistribution of the new Healthy Start children’svitamin drops (see www.healthystart.nhs.uk).Parents can get more information on vitamin dropsfrom their health visitor or GP.

29


FolateB vitamins: thiamin, riboflavin and niacin

Why children need the B vitamins thiamin,riboflavin and niacin

B vitamins are particularly important for the brainand nervous system. The body also needs these Bvitamins – thiamin, riboflavin and niacin – to beable to use the energy (calories) in food.


Average intakes of these vitamins are higher thanthe Reference Nutrient Intakes, with few childrenaged 11/2-41/2 years having intakes below thoseamounts.2 However, those children with low intakesneed particular attention.

A varied diet which provides sufficient energy andprotein will usually provide enough of thesevitamins at the same time.

Sources of thiamin and niacin

Sources of thiamin and niacin include: bread andother foods made with flour, breakfast cereals, pork(including bacon and ham), fish, yeast extract (eg.marmite) and potatoes.

Sources of riboflavin

Sources of riboflavin include: milk and milkproducts such as yoghurt; poultry; meat; oily fish(such as tuna, salmon or sardines); and eggs. Milkand milk products provide about 50% of the dailyriboflavin intakes for children aged 11/2-41/2 inBritain.2

For more information on sources of thiamin,riboflavin and niacin, see Appendix 2.

Why children need folate

Folates are a group of compounds, found infoods, which collectively are known as ‘folate’ or‘folic acid’.

Folate is an essential vitamin for many vitalmetabolic processes, and deficiency can lead to aparticular type of anaemia known asmegaloblastic anaemia.


Accurate dietary assessment of folate is difficult,but intakes among children aged 11/2-41/2 yearsappear to be adequate.2

Children obtain over a third of their folate fromcereal products, particularly breakfast cereals,about a fifth from vegetables, potatoes andsnacks, and almost a fifth from milk and milkproducts.2

Sources of folate

Sources of folate include green leafy vegetablesand salads, oranges and other citrus fruits, liver*and yeast extract as well as foods which havebeen fortified including breakfast cereals andsome breads.

Folate is partly destroyed by prolonged heating,for example by overcooking food or by heating itand keeping it for long periods.

For more information on sources of folate, seeAppendix 2.

* Liver, including liver pâté, is very rich in vitamin Awhich can be harmful in large amounts (see page 27). Itis recommended that these foods are given to childrenno more than once a week.20

30


Vitamins (continued)

Why children need vitamin B6

Vitamin B6 is the name given to a whole group ofsubstances that are commonly found in bothanimal and vegetable foods and which areinvolved in a number of body processes involvingamino acids (the protein building blocks).


Deficiency is rare. If children have a varied dietthey are unlikely to be deficient in vitamin B6.

Sources of vitamin B6

Good sources of vitamin B6 include liver*, redmeat, poultry, oily fish, bananas, potatoes, wholegrain cereals and nuts.

Vitamin B6

Why children need vitamin C

Vitamin C has an important role in preventingdisease and maintaining good health. The bodyneeds vitamin C to produce and maintain collagen,the foundation material for bones, teeth, skin andtendons. It is also important in wound healing. It issuggested that vitamin C has a role as anantioxidant vitamin in preventing damage to cellsand tissues. Vitamin C may also assist theabsorption of iron in the diet if both nutrients arepresent in the same meal.


The Reference Nutrient Intake for children over 1 year for vitamin C is 30mg a day.1 In a nationalstudy of children aged 11/2-41/2 years,2 38% ofchildren had intakes of vitamin C below theReference Nutrient Intake.

Lower intakes of vitamin C are reported in childrenof lower socioeconomic status and in children livingin Scotland. These lower intakes are attributable tothe lower intakes of fruit and vegetables, which arethe major source of vitamin C.

Children currently obtain 50% of their vitamin Cfrom soft drinks and fruit juice, with soft drinks(such as blackcurrant drinks) contributing 30% ofvitamin C. Vegetables and potatoes contributed 19%of total vitamin C intake, 13% of which was frompotatoes and savoury snacks. Fruit contributed only15% of total daily vitamin C.

The under-5s in the UK currently eat too little fruitand vegetables and the variety is limited. Thenational study mentioned above found that peasand carrots are the vegetables most commonlyeaten by the under-5s. Leafy green vegetables wereeaten by less than 39% of children, and rawvegetables and salad were eaten by less than aquarter of children during the 4-day study period.The average intake of all vegetable foods(excluding baked beans and potatoes) reportedamong children aged 11/2-41/2 years was 27g a day.2

In the same survey fruit intake averaged 50g a day,two-thirds of which was apples and bananas. Therecommendation to offer fruit and vegetables at

Vitamin C

Why children need vitamin B12

Vitamin B12 interacts with folate and vitamin B6.Together these vitamins help the body to build upits own protein, especially for nervous tissue andred blood cells.


Vitamin B12 is found almost exclusively in animalproducts.

Deficiency of this vitamin in under-5s is virtuallyunknown except when animal products are verystrictly excluded from the diet (for example, vegandiets and more restrictive diets).

Sources of vitamin B12

All foods of animal origin contain vitamin B12 – forexample meat, fish and milk. Some other foodsare fortified with vitamin B12, such as fortifiedbreakfast cereals and some yeast extracts.

Vitamin B12

* Liver, including liver pâté, is very rich in vitamin A which can beharmful in large amounts (see page 27). It is recommended thatthese foods are given to children no more than once a week.20

31


each meal and with some snacks each day (see 5 ADAY above) would ensure adequate vitamin C (andfolate) intakes.

It is important that fruit and vegetables are eatenevery day as vitamin C cannot be stored in thebody.

Sources of vitamin C

Sources of vitamin C include: fruit and fruit juices,potatoes (including chips) and other vegetables.Citrus fruits such as oranges are particularly goodsources as are red and green peppers, springgreens, blackcurrants and strawberries. Some drinksare also fortified with vitamin C (see Drinks for theunder-5s on page 47).

For more information on sources of vitamin C, seeAppendix 2.

5 A DAY

Children and adults are advised to eat at least five portions of fruit and vegetables every day. Thisshould preferably include two portions of fruit (one can be fruit juice) and three portions ofvegetables. (Dark green and orange vegetables are particularly encouraged.)

Children under 5 are encouraged to have five different tastes of fruit and vegetables every day.This will encourage them to accept a wider variety of these foods and eat more fruit andvegetables as they get older and their appetite increases.

Children under 5 in child care should have fruits and vegetables offered as part of all their mainmeals. Snacks provide an opportunity for children to try new types of fruits and vegetables.Examples of good snacks can be found on pages 45 and 55.

Some tinned and dried fruits contain added sugar and some tinned vegetables and purchasedvegetable dishes may also be high in salt. Carers should look for fruit and vegetable productswhich do not have salt and sugar added, but fresh, frozen, dried and tinned varieties can beincluded in the diet.

Fruit juice (100% juice) can be included as a portion of fruit, but fruit juices contain sugar andacid that can damage teeth and should be served diluted, and preferably with meals. For moreinformation about fruit juices and other drinks, see page 49.

32


Minerals

There are a number of minerals in the dietincluding iron, calcium, zinc, copper, iodine,magnesium, phosphorus, potassium andselenium.1 Reference Nutrient Intakes have beenset for all these minerals. Low intakes of iron andzinc have been reported in the diets of the under-5s. Sodium (which is found in salt) is alsodiscussed here as there are recommendations toreduce the amount of sodium in the diet.

Why children need iron

Iron is essential for the function of several bodysystems and particularly as part of the pigment inred blood cells called haemoglobin, which carriesoxygen. A deficiency in iron can cause anaemia.Iron deficiency means that the blood transportsless oxygen for the body’s needs and so limits theperson’s ability to be physically active. Childrenwith iron deficiency will be pale and tired andtheir general health, resistance to infection,appetite and vitality will be impaired.23 Sometimesthere are no apparent symptoms and irondeficiency may be undetected. Prevention of irondeficiency is important because, apart from theseimmediate effects, it is suggested that irondeficiency in children has an immediate and longerterm impact on intellectual performance andbehaviour.24, 25

How much iron do children need? Are theygetting enough?

The current Reference Nutrient Intakes for iron are:

• 6.9mg a day for children aged 1-3 years, and

• 6.1mg a day for children aged 4-6 years.

The higher requirement for the younger age groupreflects their increased needs during this period ofrapid growth and development.

Deficiency of iron is common in most countries,especially among children aged 1-3 years. It canbe assessed either by measuring the amount ofiron in the diet, or by measuring the amount ofiron being carried in the blood (haemoglobin).

Eighty-four per cent of children in Britain haveintakes below the Reference Nutrient Intake foriron and almost one in five have very low intakes.2

Iron

Preventing iron deficiency: what can help?

• Where an infant is not being breastfed, infantformula (which contains added iron) should be usedrather than cow’s milk until the age of 12 months. Ithas been suggested that, if there are concerns aboutthe adequacy of iron in a child’s diet, it might be wiseto extend the use of these milks into toddlerhood.9

These milks should be used as part of a balancedweaning diet. Where an infant is being breastfed it isimportant to provide a variety of weaning foods from6 months.

• Overdependence on milk puts toddlers at risk of irondeficiency, particularly where children do not havegood intakes of foods known to enhance iron status,such as meat or fruit. Offering milk drinks after mealsrather than during meals will help to ensure thatchildren eat a variety of foods.

• For older children, diets that provide plenty of ironhave lots of meat*, poultry, fish and fruits andvegetables. Children who do not eat meat or fishrequire a diet of variety containing foods such ascereal foods, pulses, finely ground nuts, vegetablesand fruit. For more information about vegetariandiets, see page 51.

• Although iron from plant foods is not absorbed bythe body as well as iron from animal sources, thereare ways of increasing the amount absorbed:

– Foods with lots of vitamin C may help the body absorb iron if eaten at the same time. Fruit andfruit juices, tomatoes and some green vegetablesare good sources of vitamin C. Having a fruit juicealong with an iron-fortified breakfast cereal, forexample, will provide a good start to the day.

– Meat* also helps the absorption of iron from vegetable foods.

• Some foods can hinder the absorption of non-haemiron from foods. For example, tannic acid in tea andcoffee can reduce the amount of iron absorbed. It isadvisable not to give these drinks to children. If givenat breakfast, for example, they would hinder theabsorption of the iron in a fortified breakfast cereal. Iftea or coffee is given it should be very weak, and beserved without sugar, and should only be givenbetween meals.

* Meat, meat products and meat dishesBecause of food scares in the past, some parents may be concernedabout giving meat to children. However, meat is a very importantsource not only of iron but also of zinc, another essential nutrient.

33


Children aged 11/2-41/2 years have been reported toconsume on average about 5.5mg of iron a day.2

Iron deficiency is frequently reported in studies ofthe under-5s and the national survey of childrenaged 11/2-41/2 years found that 1 in 12 childrenoverall, and 1 in 8 of those aged 11/2-21/2 had lowhaemoglobin levels in their blood.2 For children inpoorer areas it is estimated that 1 in 6 whitechildren between the ages of 1 and 2 years areiron-deficient.26 The incidence of iron deficiency isknown to be greater among children from ethnicminority groups and a national study found that upto one-third of toddlers from three different Asiangroups living in the UK had iron deficiency.27

Another measure of iron status is to measure theamount of iron stores in the blood (measured asserum ferritin). Among children aged 11/2-41/2 years,1 in 5 children had low iron stores, and 1 in 20children had very low iron stores, measured as lowserum ferritin.2

Causes of iron deficiency

The risk of iron deficiency among young children ishighest among those under 3 years, as this is a timeof rapid growth. During this period children needto double the iron stores in their body. Babies bornprematurely have lower stores of iron at birth andmay also experience rapid catch-up growth, whichdemands more iron. These factors make them morevulnerable to iron deficiency.

Iron deficiency is more often associated withprolonged milk feeding (for example where avariety of foods are not introduced from 6 monthsof age and where milk continues to be the mainfood source during the first years of life) or aweaning diet which contains little iron.Overdependence on milk where this displaces iron-rich or iron-enhancing foods is significantly relatedto low iron status in pre-school children.28 Asianchildren consuming more than 600-700ml of cow’smilk daily have been shown to be at high risk ofiron deficiency.2 It has been suggested that the lackof manufactured meat-based weaning foods suitablefor those who require halal foods may contribute tolow iron intakes among infants of Asian origin.29

Vegetarian and vegan children are also at greaterrisk of iron deficiency although this can be avoidedand research has shown that adequate iron status isachievable with vegetarian diets.30 Some foods anddrinks inhibit the absorption of iron and maytherefore contribute to iron deficiency. For example,

tea drinking has been associated with poorer ironstatus among pre-school children.31

Haem iron from animal sources is absorbed moreeasily into the body than non-haem iron fromvegetable sources. However, only a smallproportion of the iron consumed by under-5s –just over 5% – is haem iron.2 Children’s lowintakes of haem iron reflect their relatively lowintakes of meat and meat products which are veryimportant sources of iron. In a national survey ofchildren, only half of the children ate beef, beefdishes, poultry or sausages during the four-dayrecording period, and less than 20% of childrenate other meat and meat products during thatperiod. The main sources of non-haem iron in thediets of children aged 11/2-41/2 years were fortifiedcereals and cereal products, which accounted forhalf the total iron intake.2

Sources of iron

There are two forms of iron in foods:

• haem iron, which is found in foods of animalorigin such as meat and meat products and oilyfish, and

• non-haem iron, which is found in foods of plantorigin such as cereals and vegetables.

Haem iron is found in foods of animal origin suchas beef, lamb, chicken and turkey, liver* andkidney, and in some fish such as sardines andtuna. Haem iron is absorbed into the body moreeasily than non-haem iron.

Non-haem iron is found in foods of plant originincluding cereal foods like bread, pulses such aspeas, beans and lentils, dried fruits and greenvegetables. It is also found in fortified breakfastcereals. The absorption of non-haem iron may beenhanced if foods or drinks rich in vitamin C areconsumed at the same time.

The use of iron-fortified infant formula or breastmilk during the first year of life is recommendedand there is also some evidence that continuingformula milk into the second year of life reducesiron deficiency.32 However, formula milks areexpensive and encouraging a varied diet will havelonger term benefits.

For more information on sources of iron, seeAppendix 2.

* Liver, including liver pâté, is very rich in vitamin A which can beharmful in large amounts (see page 27). It is recommended thatthese foods are given to children no more than once a week.20

34


Minerals (continued)

Why children need calcium

Calcium is required for building and maintainingbones, for the transmission of nerve impulses andmuscle actions and for many other bodyfunctions.


The current Reference Nutrient Intakes for calciumintake among children are:

• 350mg a day for 1-3 year olds, and

• 450mg a day for 4-6 year olds.1

The majority of children under 5 have adequatecalcium intakes, with average intakes of about600mg a day. About 50% of the calcium in thediets of under-5s comes from milk.2 For moreinformation about milk drinking in the under-5ssee page 47.

It is important to ensure that children who do nothave milk or dairy products have sufficientcalcium, for example in a soya drink which hasbeen fortified with calcium, or from tinned fishmashed with the bones. For more informationabout dairy-free diets, see page 52.

Sources of calcium

Sources of calcium include: milk, soya drinkfortified with calcium, yoghurt, cheese, cheesespread, bread, tinned fish (eaten with the bones),tofu, egg yolk, pulses such as beans, lentils andchick peas, green leafy vegetables and groundalmonds.

For more information on sources of calcium, seeAppendix 2.

Zinc is also involved in the immune system, theutilisation of vitamin A, and in wound healing.Although it is known to have all those functions,more research is needed before the role of zinc canbe defined more precisely.


The Reference Nutrient Intakes for zinc are:

• 5mg a day for children aged 1-3, and

• 6.5mg a day for children aged 4-6 years.1

Lower intakes of zinc than these among childrenare frequently reported. In a national study of 11/2-41/2 year olds, more than 70% of children hadintakes below the Reference Nutrient Intakes. Alarge proportion of children had very low intakes:14% of under-4s and 37% of 4-6 year olds.2, 34

A third of zinc in the diets of the under-5s isprovided by milk and milk products, a quarter bycereals and cereal products, and a quarter frommeat and meat products. The intake of zinc hasbeen shown to go down relative to energy intake aschildren get older, and as the intake of milkdeclines.2 An increase in the intake of meat andmeat dishes will ensure a higher zinc intake. Forthose not eating meat, whole grain cereals andbreakfast cereals, milk, milk products and eggsshould be included regularly in the diet.

Sources of zinc

Sources of zinc include meat, eggs, milk, cheese,whole grain cereals, nuts and pulses.

Calcium

Why children need zinc

Zinc plays a major role in the functioning of everyorgan in the body. It is needed for normalmetabolism of protein, fat and carbohydrate and isassociated with the hormone insulin whichregulates the body’s energy.

Zinc

Sodium in the diet

Sodium is essential but too much can be potentiallydangerous for young children. Their kidneys are notyet fully developed and cannot excrete excessamounts of sodium, which may accumulate andcause harm.

How much sodium do children need? Are theygetting too much?

The main source of sodium in the diet is as salt(also called sodium chloride), added to

Sodium

35


Copper

manufactured foods and used in cooking and at thetable. It is generally agreed that most people inBritain eat too much salt and there is evidence thatthis leads to raised blood pressure in later life.33

Accustoming children to food which is salty early inlife may encourage a lasting taste for salty foods.The population targets for average salt consumptionare:33

• 1-3 year olds: no more than 2g salt (equivalent toabout 800mg sodium) per day

• 4-6 year olds: no more than 3g salt (equivalent toabout 1,200mg sodium) per day.

Little data are available on the salt intakes of infantsand very young children but estimated averageintakes based on dietary intakes of children aged11/2- 41/2 years suggest that intakes are in the regionof 1,300-1,500mg of sodium per day (equivalent to3.3g-3.8g of salt).2 It is estimated that 4-6 year oldshave about 5g of salt a day..34 Children whoregularly eat snack foods such as crisps and othersavoury snacks, processed meat (such as salami orham), cheese and tinned foods such as beans orspaghetti in sauce, are probably getting far moresalt than they need. Salt should not be added to thediet of the under-5s in cooking or at the table.

Sources of sodium

Children should not eat foods which are high insodium too often. Foods high in sodium include:sauces, soups, bacon, ham, sausage, smokedcheese, smoked fish, crisps, salted snacks and somebreakfast cereals. Take-away and fast foods such aspizzas, burgers and coated chicken products arealso likely to be very high in salt. More informationon sources of sodium in foods and dishes can befound in Eating Well for Under-5s in Child Care:Training Materials (see page 87).

Fresh meat and poultry and all fresh and frozenfruit and vegetables are low in sodium and aresuitable for children, as are unprocessed breakfastcereals such as porridge.

Other mineralsA number of other minerals have a ReferenceNutrient Intake and these are summarised brieflybelow.

Copper is an essential component of manysubstances which control body functions. Copperintakes have been found to be lower than theReference Nutrient Intake among about a third ofunder-5s.2 We do not yet know whether thehealth of those with low intakes is compromised.No tests are yet available to make this assessment.Copper is found in a wide variety of foods but isfound particularly in vegetables, fish and liver*.

Iodine

Iodine helps to make thyroid hormones necessaryfor maintaining the metabolic rate, and in infantsit is essential for the development of the nervoussystem. Iodine deficiency is now rare in the UKbut is still common in many areas of the world,where infants born to mothers with severe iodinedeficiency are likely to suffer mental retardation.Iodine is found in milk and fish in particular andintakes are generally in excess of requirements.Very high intakes can be toxic.

Magnesium

Magnesium is important for the development ofthe skeleton and for maintaining nerve andmuscle function. The main sources of magnesiumin the diet are cereals and green vegetables, withcereal foods providing about a third of dailymagnesium intake.2

* Liver, including liver pâté, is very rich in vitamin A which can beharmful in large amounts (see page 27). It is recommended that thesefoods are given to children no more than once a week.20

36


Minerals (continued)

Potassium helps to regulate body fluids and alsohas a role in nerve and muscle function. It istherefore important for children to have anadequate intake. A large range of foods containpotassium and an inadequate intake is unlikely ifchildren have a varied diet. Potassium isparticularly abundant in vegetables, potatoes, fruitand juices.

Potassium

Selenium is involved in the mechanism whichprotects the body from damage inside theindividual cells due to oxidation. There is littleevidence to suggest that low intakes of seleniumare associated with ill health in the UK. Seleniumis found mainly in cereals, meat and fish, withcereals contributing about half of selenium intakein the UK.

Selenium

Examples of good sources of vitamins and mineralsin foods can be found in Appendix 2. Details of theDietary Reference Values for all nutrients for under-5s are given in Appendix 3.

Phosphorus

About 80% of the phosphorus in the body ispresent in the bones and phosphorus, withcalcium, provides rigidity to the skeleton.Phosphorus is found in all plant and animal cellsand therefore children will get enoughphosphorus as long as they eat a varied diet.

Carrot and a flowerThomas, aged 4

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References

1 Department of Health. 1991. DietaryReference Values for Food Energy andNutrients for the United Kingdom. Report onHealth and Social Subjects No. 41. London:HMSO.


Years. Volume 1: Report of the Diet andNutrition Survey. London: HMSO.

3 Department of Health. 2006. Health Surveyfor England 2004. Accessed fromwww.ic.nhs.uk/pubs/hsechildobesityupdate

4 Jago R, Baranowski T, Baranowski JC,Thompson D, Greaves KA. 2005. BMI from 3-6 years of age is predicted by TV viewing andphysical activity, not diet. International Journalof Obesity; 29: 557-564.

5 Reilly JJ, Jackson DM, Montgomery C, Kelly LA,Slater C, Grant S, Paton JY. 2004. Total energyexpenditure and physical activity in youngScottish children: mixed longitudinal study.The Lancet; 363: 211-212.

6 Sproston K, Primatesta P (eds.) 2003. HealthSurvey for England 2002: The Health ofChildren and Young People. London: TSO

7 Scottish Executive 2005. The Scottish HealthSurvey: Volume 3 Children. Edinburgh:Scottish Executive.

8 Wallace W. 1996. Food for thought. NurseryWorld; 96: 8-9.

9 Department of Health. 1994. Weaning andthe Weaning Diet. Report on Health andSocial Subjects No. 45. London: HMSO.

10 Rogers J, Emmett P and the ALSPAC StudyTeam. 2002. Fat content of the diet amongpre-school children in Britain: relationshipwith food and nutrient intakes. EuropeanJournal of Clinical Nutrition; 56: 252-263.

11 Yehuda S, Rabinovitz S, Mostofsky DI. 1999.Essential fatty acids are mediators of brainbiochemistry and cognitive functions. Journalof Neuroscience Research; 56: 565-570.

12 Department of Health. 1994. Diet andCardiovascular Disease. London: HMSO.

13 Scottish Executive. 2006. NutritionalGuidance for Early Years. Edinburgh: ScottishExecutive.

14 Department of Health. 1989. Dietary Sugarsand Human Disease. Report of theCommittee on Medical Aspects of FoodPolicy. London: HMSO.

15 Hinds K, Gregory J. 1995. National Diet andNutrition Survey: Children Aged 11/2 to 41/2

Years. Volume 2: Report of the DentalSurvey. London: HMSO.

16 Holt RD, Winter GB, Downer MC, Bellis MJ, HayIS. 1996. Caries in pre-school children inCamden in 1993/94. British Dental Journal;181: 405-411.

17 Burnett C, Wilkins G. 2002. Managingchildren with constipation. Journal of FamilyHealth Care; 12: 127-132.

18 Edwards CA, Parrett AM. 2003. Dietary fibrein infancy and childhood. Proceedings of theNutrition Society; 62: 17-23.

19 Hoekstra JH. 1998. Toddler diarrhoea: more anutritional disorder than a disease. Archivesof Disease in Childhood; 79; 2-5.

20 Scientific Advisory Committee on Nutrition.2005. Review of Dietary Advice on Vitamin A.London: TSO.

21 Health Education Authority. 1999. Sun SafetyGuidelines for Schools. Available through NICEat www.publichealth.nice.org.uk

22 Shaw NJ, Pal BR. 2002. Vitamin D deficiencyin UK Asian families: activating a newconcern. Archives of Disease in Childhood,86: 147-149.

23 Oski FA. 1993. Iron deficiency in infancy andchildren. New England Journal of Medicine;329: 190-193.

24 Walter T. 1993. Impact of iron deficiency oncognition in infancy and childhood. EuropeanJournal of Clinical Nutrition; 47: 307-316.

25 Lansdown R, Wharton BA. 1995. Iron andmental and motor behaviour in children. In:Iron: Nutritional and PhysiologicalSignificance. The Report of The BritishNutrition Foundation’s Task Force. London:Chapman and Hall: pages 61-74.

26 James J, Evans J, Male P, Pallister C, HendrikzJK, Oakhill A. 1988. Iron deficiency in innercity pre-school children: development of ageneral practice screening programme in aninner city practice. Journal of the RoyalCollege of General Practitioners; 38: 250-252.

27 Lawson MS, Thomas M, Hardiman A. 1998.Iron status of Asian children aged 2 yearsliving in England. Archives of Disease inChildhood; 78: 420-426.

28 Thane CW, Walmsley CM, Bates CJ, Prentice A,Cole TJ. 2000. Risk factors for poor iron statusin British toddlers: further analysis of datafrom the National Diet and Nutrition Surveyof children aged 11/2 to 41/2 years. PublicHealth Nutrition; 3: 433-440.

29 Williams S, Sahota P. 1990. An enquiry intothe attitudes of Muslim Asian mothersregarding infant feeding practices and dentalhealth. Journal of Human Nutrition andDietetics; 3: 393-402.

30 Sanders TAB. 1995. Vegetarian diets andchildren. Pediatric Clinics of North America;42: 955-965.

31 Watt RG, Dykes J, Sheiham A. 2000. Drinkconsumption in British preschool children:relation to vitamin C, iron and calciumintakes. Journal of Human Nutrition andDietetics; 13: 13-19.

32 Wall CR, Grant CC, Taua N, Wilson C,Thompson JM. 2005. Milk versus medicine forthe treatment of iron deficiency anaemia inhospitalised infants. Archives of Disease inChildhood; 90: 1033-1038.

33 Scientific Advisory Committee on Nutrition.2003. Salt and Health. London: TSO.

34 Gregory J, Lowe S, Bates CJ, Prentice A,Jackson LV, Smithers G, Wenlock R, Farron M.2000. National Diet and Nutrition Survey:Young People Aged 4-18 Years. Volume 1:Report of the Diet and Nutrition Survey.London: TSO.

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Chapter 4 Infant nutrition

This chapter summarises current advice on infantfeeding and weaning. Infants are defined as thoseunder the age of 12 months.

Nutrition in the early years of lifeis a major determinant of growthand development and it may alsoinfluence adult health. Weaning –the introduction of solid foods tobabies as they become lessdependent on milk – coincideswith a period of rapid growthand development, so a good dietduring this period is crucial. Forsources of information aboutinfant feeding, see Appendix 5.

Milk for babies

Infants up to 6 months of agereceive all their nutritionalrequirements from breast milk orinfant formula.

Breast milk

Breast milk is universallyrecognised as providing the bestnutrition for babies and shouldbe considered the method ofchoice for infant feeding. Thebalance of nutrients is uniquelyideal for a young baby andcannot be matched by amanufactured product. Breastmilk is easily digested andhygienic and contains importantantibodies that help babies tofight infections. In its InfantFeeding Recommendation,1 theDepartment of Healthrecommends that babies areexclusively breastfed for the first6 months (26 weeks) of life.

Evidence shows that infants whoare breastfed experience fewergastrointestinal and respiratoryinfections and are less likely todevelop juvenile onset diabetesor to develop allergies, and thereis some evidence that breastfedbabies are less likely to be obesein later childhood.1 In addition,breastfeeding mothers have alower risk of developing pre-menopausal breast cancer, aremore likely to return to their pre-pregnancy weight, and will havea delayed resumption of theirmenstrual cycle.

My baby sister drinkingElla, aged 4

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Breast milk can provide the maindrink throughout the first year oflife, and beyond, if motherschoose to continue breastfeeding.Breastfeeding mothers themselvesshould be well nourished andseek advice from healthprofessionals to ensure that theyare eating and drinkingappropriately.

Mothers who return to work butwho wish to continue providingbreast milk for their babiesshould be encouraged to do so.Advice on expressing and storingbreast milk can be obtained froma health visitor or breastfeedingcounsellor. Breastfeeding supportgroups are available throughoutthe country through organisationssuch as the National ChildbirthTrust, the Association ofBreastfeeding Mothers and LaLeche League. Contact details forthese organisations are given inAppendix 5. For informationabout the responsibilities ofemployers, via health and safetylegislation, to supportbreastfeeding mothers in theworkplace, see the EqualOpportunities Commissionwebsite www.eoc-law.org.uk.

Advice for carers

• Carers should supportbreastfeeding mothers andencourage them to continueproviding breast milk. Motherswho are breastfeeding and whomay wish to feed their baby inthe childcare setting shouldhave warm, private facilitiesmade available to them.

• Expressed breast milk providedfor babies in child care shouldbe clearly labelled with thechild’s name and the date,stored in a refrigerator and onlybe used for that child. Anyexpressed milk left over at theend of the day should bereturned to the parent orguardian.

See also Giving bottle feeds on the right.

Infant formula

There are a number of artificialmilks available for babies, calledinfant formula. If a baby is notbeing breastfed, only anappropriately modified formulababy milk can meet his or hernutritional needs. The advicegiven on the packet or tin mustbe followed. If there is any doubtabout the suitability of the milk itis best to ask a health visitor foradvice.

Infant formulas are usuallymanufactured from cow’s milkbut some are formulated fromsoya milk. Soy-based infantformula should only be used onthe advice of a healthprofessional or GP. Infant formulabased on cow’s milk comes intwo types: whey dominant orcasein dominant (depending onwhether whey or casein is thedominant protein). Wheydominant infant formula has aprotein content adjusted toremove much more of the caseinfrom the cow’s milk, whichmakes it a closer match to breastmilk. Whey dominant formulasare usually suggested for veryyoung babies. Casein dominantformulas are marketed as ‘moresatisfying’ and many parentschange to these milks as theirbabies get older, although there isno evidence to suggest that thesemilks are more suitable and thereis anecdotal evidence that babieson this type of formula are morelikely to be constipated.

Despite powerful marketingmessages there is nomanufactured breast milk

substitute which can mirror thecomposition of breast milk. Breastmilk is the best food for babies, it is free, requires no preparation,is microbiologically safe and isalways at the right temperature. If babies are not breastfed, infantformula is recommended as themain drink during the first year oflife. Ordinary cow’s milk is notsuitable as a main drink before 12 months of age.

Advice for carers

• For those babies given infantformula it is essential that feedsare prepared correctly andsafely. Because powderedinfant formula is not sterile,wherever possible feeds shouldbe made up freshly for eachfeed using boiled water that ishotter than 70oC. (This meanswater that has been boiled andleft to cool for about 30minutes.) Alternatively, ready-

Giving bottle feeds• Babies who are bottle-fed should

be held and have warm physicalcontact with an attentive adultwhile being fed.

• Babies should never be leftpropped up with bottles as this is both dangerous andinappropriate to babies’emotional needs.

• Bottles, teats and cups used forinfants under 6 months of ageshould be thoroughly cleaned andsterilised. The teats of bottles forolder infants should bethoroughly cleaned.

• Recent guidance advises thatbottle feeds should not be madeup in advance and re-heated, butshould be made up whenrequired, using water at 70oC orabove and cooled as appropriate.2

If at any time bottles of liquid areheated, a microwave should notbe used as the contents canbecome very hot even thoughthe container still feels onlywarm.3

Carers should support

breastfeeding mothers

and encourage them

to continue providing

breast milk.

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to-feed liquid formula can beused in childcare settings.Where parents wish to bringfeeds made up from powderedformula to the childcare setting,storage times should be kept toa minimum. Feeds should bemade as close as possible tofeed time, cooled and stored atless than 5oC. If feeds are madeup in advance, the made-upfeeds should be stored for theminimum amount of timepossible and not stored forlonger than 24 hours.

• If the carer is making up infantformula, it is preferable if it canbe made in a separate milkpreparation area and the carershould ensure that hands arewashed thoroughly andsurfaces are clean. Themanufacturer’s instructions formaking up the infant formulashould be followed carefully.This includes using the correctamount of powder and water,using only freshly boiled water(either tap water or bottledwater that is suitable forinfants), and sterilising allequipment before use.

• Always discard the milk left ina bottle after a baby hasfinished feeding.

See also Giving bottle feeds onpage 39.

Timing of feeds

Because children in the first yearof life are following individualfeeding and sleeping patterns, itis recommended that these arenot disrupted but whereverpossible integrated into the carer’stimetable for the day.

Weaning (starting onsolid foods)Up to the age of about 6 months,breast milk or infant formula milkwill provide all the nutrients andfluid that babies need. There isno need to give solids or non-milk drinks before about 6 months of age.1 Breastfedbabies do not need anyadditional fluids – including water– even if the weather is hot asthey will demand more frequentfeeds if they are thirsty and breastmilk composition adapts tochanging external temperatures.Formula-fed babies may needcooled boiled water to quenchthirst if the weather isexceptionally hot, but this is notreally necessary. Babies whoappear hungrier at 4-6 monthsand change their sleepingroutines may require morefrequent breast or formula milkfeeds to satisfy them.

There remains, however, someconfusion about when babiesshould be weaned. TheDepartment of Healthrecommends that babies shouldnot be given any solid foods untilthey are 6 months of age.1

However, some manufacturers’literature and some healthprofessionals suggest weaningfrom 4 months of age. Researchsuggests that currently about halfof parents wean before 4 monthsof age, so it may take some timefor the recommended pattern ofweaning at about 6 months tobecome established in the UK.4

Many health professionals preferto advise parents to wean whentheir children show develop-mental cues such as being able tosit up with some support, havingsome trunk control, showing anactive interest in food and havingthe ability to pick food up andput it to their mouth, rather thanby age alone. Weaning before 4months of age is neverrecommended, but since the

majority of families in the UK arecurrently starting to give theirbabies solids before 6 months ofage, specific recommendations onthe foods to avoid for infantsunder 6 months of age are givenon the next page.

From about 6 months of age, themajority of infants are able totake food from a spoon, chewand use the tongue. They willalso at this stage be curious aboutother tastes and textures anddevelop their hand-to-eyecoordination. By about 6 monthsof age an infant can also havefinger foods. There is noevidence that waiting until 6months to wean will affect ababy’s ability to chew. When thebaby seems ready to experiment,small spoonfuls of baby rice,puréed vegetables such as carrotsor peas or mashed potato can beoffered. Some babies will taketime to learn to take food from aspoon, so it is important to go atthe baby’s pace and smileencouragement as he or shelearns. Babies weaned at about 6months usually accept a greatervariety of foods and changes infood textures more quickly thanthose weaned earlier.

All babies should have started onsolid foods by around 6 monthsof age since at this stage babiesneed more iron and othernutrients than can be provided bymilk alone. Parents of babies whowere born prematurely needindividual advice about when tostart solid foods. Resources onfeeding and weaning prematurebabies can be found in Appendix5.

Certain foods can cause anallergic reaction in some babies.It is therefore recommended thatbabies should not be givencertain foods before 6 months ofage. See the box on the nextpage.

Rice or oat cereals are acceptableand should be given from a

41


spoon. Foods should not beadded to bottles of milk as thisdoes not allow the infant to learnhow food feels in the mouth orhow to chew, and it may causechoking. Manufactured weaningfoods (bought in packets, jars ortins) can be chosen according tothe baby’s age. It is important tooffer a good variety of tastes sothat infants get used to differentflavours.

One particularly importantnutrient for babies is iron, as by 6months the body stores of ironthat an infant is born with havebeen used up, and the babyneeds to obtain iron from thediet. (The importance of iron inthe diet is discussed in detail onpage 32.) Good sources of ironwhich can be given as purées ormash are: meat; fish such as tunaor sardines; pulses such as peas,beans and lentils; and greenvegetables. The iron from meatand some fish is easily absorbedinto the body and a daily helpingof these foods is a valuable wayof providing iron in the weaningdiet.

Texture is also important. Firstfoods should be of purée

consistency but as soon as babiesare used to taking food from aspoon, chewing and swallowing,they can be given soft lumps orfood which is mashed rather thanpuréed. As eating and chewingskills increase, minced or finelychopped foods and finger foodsshould be given and differenttextures of food should beintroduced. By about 12 months,children should be getting a goodmixed diet with three meals and,depending on their sleepingpatterns and appetite, one or twohealthy snacks each day.

It is recommended that breastfedbabies from 6 months of age (orfrom 1 month of age if mothersdid not eat well duringpregnancy), and formula-fedbabies once their milk intakedrops to 500ml a day, should begiven vitamin drops containingvitamins A, C and D. Parents orguardians can get furtherinformation from their healthvisitor or GP.

Foods to avoid before 6 months of age It is recommended that first foods given to infants younger than 6 monthsare ‘gluten-free’ foods. Gluten is found in foods such as bread, pasta orchapatis made from wheat.

Nuts and seeds – including peanuts, peanut butter and other nut spreads –should be avoided by all infants under 6 months. If babies come from afamily where parents, brothers or sisters have allergic conditions such asasthma, eczema or hayfever (known as atopic families), government advice5

is that peanuts and peanut products should be avoided for the first threeyears of life. Mothers in atopic families should also avoid peanuts andpeanut products during pregnancy and when breastfeeding.

Eggs, raw or cooked shellfish, shark, swordfish and marlin, citrus fruit andjuices should also be avoided until 6 months of age.

Foods containing plant sterols (eg. some margarines and yoghurts) shouldnot be given to under-5s. The ingredients label will indicate if the foodcontains plant sterols.

Honey should not be given to children under the age of 12 months.

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Weaning tips Up-to-date information on what foods should beavoided during weaning can be found onwww.eatwell.gov.uk.

• Soft cooked meat, fish and pulses (such as peas,beans and lentils) are suitable and important foods toinclude in the diet from 6 months.

• Offer a variety of flavours and soft textures. Between6 months and 1 year, give food which allows theinfant to learn to chew and accept a wide variety offood textures.

• Eggs given to babies or toddlers should be cookeduntil both the yolk and the white are solid.

• If using commercial weaning foods, follow themanufacturer’s instructions carefully.

• Whole cow’s milk can be used as an ingredient inweaning foods, for example to moisten mashedpotato, but cow’s milk should not be the main drinkfor infants under 1 year.

• As weaning progresses, introduce soft lumps, andfinger foods.

• Do not add salt to foods for infants.

• Do not add sugar to foods for infants. Instead usenaturally sweet fruits such as apples or bananas

• Do not add artificial sweeteners to food for infants.

Drinks for infants From 6 months of age infantsshould be introduced to drinkingfrom a cup or beaker. From theage of 1 year, they should bediscouraged from drinking from abottle.

Use an open cup or beaker ratherthan one which requires theinfant to suck the drink(sometimes called a ‘dinky feeder’or a ‘non-spill’ cup). This isbecause sucking drinks across theteeth can contribute to toothdamage (see page 51).

Tap water is suitable from 6months of age but should beboiled and cooled for youngerinfants.

Adult-type soft drinks, low-sugardrinks or ‘diet’ drinks, tea andcoffee should not be given toinfants.

Frequent use of fruit drinks,including baby juices and otherbaby drinks, should bediscouraged as they encourage asweet tooth and can contribute todental disease.

If drinks other than milk or waterare given (for example, dilutedbaby juices or baby drinks), theseshould be diluted with at least 10parts of water and confined tomealtimes. Because of the risk todental health, they should neverbe given in a feeding bottle.

Vitamin D and exposure to sunlight

Exposure to summer sunlight in outdoor play helpschildren to maintain their vitamin D status. However,childcare settings should have a ‘sun policy’, withguidelines on how long children can remain outdoors instrong sunshine and on the use of protective clothingsuch as sunhats, and sunscreen. All under-5s should beappropriately supervised at all times while outdoors.

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Hygiene and safety tips

• If dummies or comforters are used, they should bethoroughly cleaned and sterilised for infants under 6months, and thoroughly cleaned for older infants.This also applies to dummies or comforters which aredropped.

• Artificial milk feeds should be made up using boiledwater that is hotter than 70oC. (This means waterthat has been boiled and left to cool for about 30minutes.)

• Artificial milk feeds should be made up fresh for eachfeed and left-over milk should be thrown away.

• The kettle should be filled with fresh tap waterbefore boiling water for making up infant formula. Ifyou are using bottled water, only use bottled watersuitable for infants. These will say on the label thatthey are suitable for infant feeding.

• If you are serving food from a can or jar and the childis unlikely to eat all the contents, spoon a portioninto a separate dish or container before serving it tothe child. Store any unused portions according to themanufacturer’s instructions. If there are noinstructions, the safest option is to throw the unusedportion away. If food is served straight from the jarand the child does not finish it, the remainder shouldbe thrown away.

• Any uneaten food which parents have brought inshould be returned to them at the end of the day.

• Do not use unpasteurised milk, or milk-basedproducts such as cheese and yoghurt that are madefrom unpasteurised milk or mould-ripened (blue-veined) cheeses.

• Fruits and vegetables to be eaten raw should be wellwashed before eating. Carrots should be topped andpeeled. Fruit and vegetables should be peeled foryounger infants, to prevent choking.

• Whole pieces of nut should not be given to infantsor children under 5 in case of choking.

• Never leave children or infants alone while they areeating in case they choke.

References

1 Department of Health. 2003. Infant FeedingRecommendation. Accessed fromwww.dh.gov.uk

2 www.food.gov.uk

3 Puczynski M, Rademaker D, Gatson R. 1983.Burn injury related to improper use ofmicrowave ovens. Paediatrics; 72: 5.

4 Hamlyn B, Brooker J, Oleinikova K, Wands S.2002. Infant Feeding 2000. London: TSO.

5 Department of Health. 1998. Report onPeanut Allergy. Committee on Toxicity ofChemicals in Food, Consumer Products andthe Environment (COT). London: TSO.

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Chapter 5 Encouraging children to eat well

This chapter gives some practical guidelines on howto encourage under-5s in child care to eat well. Itlooks at the types of foods and drinks to offer, andgives information on vegetarian diets, special diets,food safety and hygiene issues, timing of meals andsnacks and how carers can involve parents andguardians to ensure that children eat well.

Eating a variety offoods

The role of different nutrients inensuring good health has beendescribed in chapter 3. One ofthe basic principles to ensurehealthy eating is to eat a varietyof foods. It is easier to get all thevitamins and minerals needed forgood health if a good variety offoods is eaten. It is difficult toachieve adequate intakes ofvitamins and minerals when dietsare monotonous and based onfew foods.1 A varied diet is alsoassociated with better health.2

Children do not have an inbornability to select a balanced andnutritious diet3 but increasing thevariety of available foods shouldincrease the number of differentfoods chosen. Parents and carersoften allow a child’s initialrejection of a new food todetermine whether that food isoffered again, yet research hasshown that continued exposureto a food will increase thelikelihood that the child will eatit.4 It has been shown, however,that a new food will not bechosen unless the child has tastedit, which suggests that it isimportant to encourage childrento taste all the foods offered at ameal.5 Parents or guardians,particularly those on lowincomes, may be unwilling toexperiment with new foodswhich may be rejected and thenthrown away. Carers can oftenoffer a wider choice and maytherefore play an important partin encouraging a varied diet.

As children get older they aregenerally willing to eat a widervariety of foods, and snacksbecome an increasingly importantsource of energy and nutrients.The innate preference for foodswhich are sweet is particularlyobserved in childhood. Childrenwho are given early and

I eat an apple for my snackSiân, aged 5

45


consistent exposure to sweettastes may reject other tastes.

It is important that foods offeredto children as snacks are alsovaried. Although biscuits andcrisps are eaten regularly byabout 80% of children between11/2 and 41/2 years,6 these are notthe only or the most nutritioussnacks available. Snack foods canbe based on a variety of cerealsand cereal products as well as onfruits and vegetables. Some ideasfor a variety of different snackfoods are given on the right, andon page 55.

There are some vitamins andminerals which have been shownto be consumed by children inamounts below the ReferenceNutrient Intakes. These includevitamins A and C and theminerals iron and zinc. Increasingthe amounts of different meats,fish, cereals and fruit andvegetables in the diet is likely toimprove the intake of all thesenutrients. Diets which are notvaried are often particularly lowin fruit and vegetable foods.Children from poorer families aremore likely to have a low intakeof fruit and vegetables.7

Eating a varied diet Children should be encouraged toeat a varied diet. They should eatfoods from each of the four mainfood groups every day. The fourmain food groups are:

• bread, other cereals andpotatoes

• fruit and vegetables

• milk and dairy foods, and

• meat, fish and alternatives suchas pulses (peas, beans andlentils), eggs, vegetable proteinsand soya.

A varied diet is associated withbetter health as it is more likely tocontain all the vitamins andminerals the body needs.

Suggested fruits and vegetables for mealtimes1/2 to 1 heaped tablespoon of cooked vegetables such as peas, sweetcorn,carrots, cabbage, courgettes or swede

1/2 to 1 heaped tablespoon of beans such as butter beans, chick peas orlentils

1-2 broccoli or cauliflower florets

4-5 green beans

Small handful of salad leaves

1/4 -1/2 sweet potato

1 small parsnip

Small slice of squash or marrow

1/2 tablespoon of dried fruit

1-2 tablespoons of stewed fruit

1-2 tablespoons of canned fruit in juice

100-150ml 100% diluted fruit juice

Suggested fruits and vegetables for snacks1/2 medium carrot cut into sticks

2-3cm piece of cucumber in sticks

1 small celery stick cut into pieces

4 cherry tomatoes or 4 small tomato quarters

1 ring of red, yellow or green pepper

1/2 to 1 small banana

1/2 apple or pear

1 plum

1/2 to 1 kiwi

1/4 -1/2 large orange or 1 small orange, clementine or satsuma

1 small slice of melon or pineapple

1 tablespoon of berries such as blackberries, raspberries or fresh currants

4-6 strawberries

8-10 grapes

Fruit and vegetables

Fruit and vegetables are nowthought to be particularlyimportant for good health. Inadults the antioxidant nutrientsthey contain protect againstchronic diseases such as coronaryheart disease and cancer. Under-5s should be encouraged to have

tastes of at least five differentfruits and vegetables every day toaccustom them to eating thesefoods when they get older.8 Veryyoung children may only be ableto manage small amounts butthose over 2 years of age shouldbe offered child-sized portionswith all meals and with somesnacks.

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It is worth experimenting withdifferent vegetables and vegetabledishes to find those that areacceptable. Some children mayreject cabbage but enjoy ‘bubbleand squeak’ (cabbage and potatomixed together). Others may findstir-fry vegetables moreinteresting than boiled ones.Carrots, red peppers andsweetcorn are appealing incolour, taste and texture. Peas area popular and familiar vegetablefor most children. Some childrenlike raw vegetables more thancooked ones. There is someevidence that children aged 2-6years who are exposed torepeated tasting of vegetablesover 14 days will increasinglyaccept and enjoy them.9

Food for all

Food is an important part ofeveryone’s lives. Eating together,having special foods and avoidingparticular foods are all intimatelyrelated to aspects of people’sfamily life, cultural, religious andintellectual beliefs. It is importantto recognise that the foodavailable for any group of peopleshould be appropriate andfamiliar. It is essential to involveparents or guardians in the choiceof foods provided in child care:good communication betweenparents and those providing childcare is vital.

When planning meals for anygroup of people, the particularneeds of that group must beconsidered. Cultural and religiousdifferences are commonlyexpressed in food preferencesand food avoidances. Providingthe right ingredients is not theonly factor to consider: foodshould look and taste familiar aswell.

All food activities should allowfor cultural differences: activitiesinvolving food give children the

opportunity to learn about newand different foods. Holidays,festivals and religious celebrationsof various cultures provide avaluable opportunity to celebratedifferences in food experiences.

Some of the differences in foodchoice commonly observed bythose from different religious andcultural groups are summarised inAppendix 4. It is important toemphasise that there may beindividual differences in foodchoices between families, andthose providing child care shouldnot make assumptions aboutanyone’s food preferences. It isimportant to find out about eachchild from his or her parent orguardian.

Physical activity

Physical activity is a term used todescribe body movement. Itincludes:

• everyday body movementssuch as walking, playing, orclimbing stairs, and

• movement which is oftendescribed as ‘exercise’. Forchildren this might be, forexample, running, playingfootball, or playing in aplayground.

The more the body moves, themore energy (or calories) is usedup. The relationship betweenenergy (calorie) intake andphysical activity is explained onpage 20.

Activity can be encouraged bothindoors and outdoors. Outdoorplay gives children theopportunity to ‘let off steam’ andprovides many moreopportunities for them to bephysically active. Most childrenare attracted to outdoor play ifthey are offered a range ofsuitable activities.

The Department of Healthrecommends that all childrenfrom 2 years of age shouldachieve a minimum of 60 minutesof moderate intensity activityevery day. (‘Moderate intensity’means enough to make them feelwarm and slightly out of breath.)At least twice a week this shouldinclude activities that improvebone health, muscle strength andflexibility.10 It is essential thatthere is outdoor space wherechildren can play, or access to anoutside area such as a garden,park or other safe open space. Carers need to timetable periodsof activity into the children’s dailyroutine and encourage children tobe active throughout the year.Children in child care should alsohave access to toys for active play– for example balls, hoops andskipping ropes.

All children, and their parents orguardians, should be respectedas individuals, and their foodpreferences and religiousrequirements should beaccommodated.

All that children bring with themto their place of child care –their race, gender, familybackground, language, cultureand religion – should be valuedin order for children to feelaccepted and accepting ofthemselves. It is thereforeimportant to value thecontributions which differentcultures and nationalities maketo the variety of foods eaten inthe UK today.

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Carers should ensure that outdoorplay equipment is safe. Allchildren should be closelysupervised during sand and waterplay and should not be left alonewhile playing outdoors. Carersshould be aware that somechildren’s dress may restrict themin outdoor play and it may benecessary to sensitively adjusttheir clothing for outdooractivities. Children playing outsideshould be appropriately dressedfor cold or rainy weather withcoats and jackets buttoned upand scarves, mittens, boots andhats used as necessary.Information about improvingoutdoor play for pre-schoolchildren can be obtained fromthe organisation LearningThrough Landscapes (see page84).

Exposure to summer sunlight inoutdoor play helps children tomaintain their vitamin D status.However, childcare settingsshould have a ‘sun policy’, withguidelines on how long childrencan remain outdoors in strongsunshine, and on the use ofprotective clothing such assunhats, and sunscreen.

Why it is important for children to be physicallyactive

• The more energy children use up, the more food they will need toeat. A child who is inactive may have a very small appetite and maynot be able to get all the nutrients he or she needs in a smallamount of food.

• Exposure to summer sunlight in outdoor play helps children tomaintain their vitamin D status (see page 28).

• Physical activity builds up muscle strength and overall fitness, anddevelops physical skills such as balance, coordination and climbingskills.

• A considerable amount of learning can take place while children areplaying outdoors. For example, they learn about the environmentaround them, and interacting with other children can contribute totheir confidence.

Worries about fatness in children

Parents or guardians who are concerned about their child being orbecoming fat should encourage and enable the child to increase theamount of exercise he or she does each day. This can include activitiesdone as part of the daily routine such as walking and climbing stairs, as wellas physically active play such as running, ball games or playing in aplayground. They may also want to restrict the amount of inactivity amongunder-5s since the amount of television viewed is typically a strongpredictor of body weight.11

Children are unlikely to become fat if they eat, while in child care, theamount and types of food recommended in this report and if they followthe general advice it gives about healthy eating and physical activity.However, if a child eats a significant amount of other foods as ‘extras’ –particularly if these are high in calories but contain few other nutrients (forexample sweets, biscuits, cakes, savoury snacks or soft drinks) – the childmay take in more calories than they use up in their daily activities.

Restricting food intake among children (ie. giving them less to eat thanthey would choose, or using ‘low-calorie’ foods that are designed for adults)may prevent children from getting all the nutrients they need for normalgrowth and development. If parents or guardians have concerns about theirchild’s weight, they should ask their GP or health visitor for advice. The GPmight refer the family to a dietitian.

Drinks for the under-5s

Milk

Milk is the main source ofcalcium for the under-5s and italso contributes substantially tothe protein, riboflavin, vitamin A,iodine and zinc intakes ofchildren in this age group.Children aged between 12months and 2 years should begiven whole milk. Semi-skimmedmilk can be introduced graduallyafter the age of 2 years, providedthat the child is a good eater andhas a varied diet.

Skimmed milk is not suitable as amain drink for children under 5years of age, as it does notcontain enough calories orvitamins.

Some children may reject milkunless some flavouring is added.Flavoured milk is usuallysweetened in some way and,

48


while this may be a useful way ofencouraging milk drinking insome children, it is better thatflavoured sweetened drinks aredrunk with meals, rather thanbetween meals, because of therisk to teeth.

Some children cannot drink cow’smilk. For those over 1 year thismay be substituted with goat’smilk or soya drinks, but these arenot suitable for infants. Inaddition it is important to notethat goat’s milk is not a suitablealternative for children who areallergic to cow’s milk as theproteins in the milk are similarand it could cause a reaction.Some of the alternative milksavailable are described on theright. There is no healthadvantage in giving milks otherthan cow’s milk to children whocan tolerate cow’s milk.

The Department of Health’sWelfare Food Scheme enableschildren under 5 to receive, freeof charge, one-third of a pint(189ml) of milk for each day theyattend approved day carefacilities for 2 hours or more. Daycare providers who have beenapproved to supply milk underthe scheme can be reimbursedthe cost of the milk they supply.This scheme will not be changedby the new Healthy Start scheme.Providers can apply direct to theWelfare Food ReimbursementUnit12 (WFRU) to take part in thescheme. Some local authoritiesadminister the scheme centrallyon behalf of some pre-schools.This provision is in addition tothe milk tokens available throughthe Welfare Food Scheme, andthe vouchers for milk, fruit andvegetables and infant formula thatwill be available through itsreplacement scheme Healthy Start.(See www.healthystart.nhs.uk fordetails.)

Breast milk

Infant formula

Follow-on infant formula

Soya infant formula

Whole cow’s milk*

Semi-skimmed cow’smilk*

Skimmed cow’s milk*,including dried skimmedmilks

Evaporated milk

Condensed milk

Soya drinks (other thansoya infant formula)

Goat’s milk*

Cow’s milk substitutessuch as oat milk, ricemilk or almond milk

The best milk for infants.

Cow’s milk specially modified for infants islabelled as such. Follow the instructionsgiven on the packet or tin when choosingand preparing infant formula.

Modified cow’s milk only suitable for infantsfrom 6 months of age.

May be given from birth but only if advisedby a doctor. These formulas contain sugar inthe form of glucose which is more harmfulto teeth than the lactose in infant formulabased on cow’s milk. Care should be takenthat infants are not left with bottles for longperiods and children should be given soyainfant formula in cups, preferably withmeals.

Not suitable for infants. Suitable for mostchildren from 12 months of age.

Not suitable for infants or children under 2years, but can be introduced gradually afterthe age of 2 years, provided that the child isa good eater and has a varied diet.

Not suitable for infants or children under 5years.

Not suitable for infants. Skimmed milkvarieties are not suitable for children.

Not suitable for infants or children.

Not suitable for infants. If children are givensoya drinks, make sure the drink is calcium-fortified. Drinks should be given in cupsbecause of the sugars content.

Not suitable for infants unlessrecommended by a paediatrician.

Not suitable for children under 5 as thesedrinks are low in calcium and protein andmay have added sugar.

Which milks to give under-5s as a main drinkInfants = children under 12 months

* Milks given to under-5s should be pasteurised.

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Soft drinks

There is a wide range of softdrinks available, most of whichare sweetened with sugars,sweeteners (for examplesaccharin or aspartame), andcommonly a mixture of both.They include:

• squashes and other drinkswhich need to be diluted

• carbonated soft drinks such ascola or lemonade, and

• fruit drinks which are drinksthat contain a proportion offruit juice as well as water andsome form of sugar and/orsweetener.

Children can be conditioned at anearly age to the sweet taste ofdrinks. High intakes of soft drinkshave been reported to lead tofrequent looser stools, poorappetites and failure to thrive.13

Data from the National Diet andNutrition Survey showed thatamong under-5s soft drinks areconsumed more frequently thanmilk, 56% of under-5s consumesoft drinks more than once a day,and children obtain a third oftheir sugar intake from drinksalone.14

Soft drinks containing sweetenersare generally not recommendedfor children. If soft drinks (suchas squashes) containing saccharinare given to the under-5s theyshould be diluted much morethan they would be for an adult –for example, a dilution of 1 partsquash to at least 10 parts water.

Soft drinks containing sugar canbe harmful to the teeth, especiallyif they are drunk frequently orstay in contact with the teeth fortoo long. If sugary drinks are

given, they should be kept tomealtimes. Soft drinks such asfruit drinks and fruit squashesshould not be given at bedtimeor during the night as thispractice increases the risk ofdental decay.

Soft drinks labelled ‘low-sugar’ or‘no added sugar’ may still harmchildren’s teeth as they often docontain some sugar and they mayalso be acidic. This is also truefor baby herbal drinks. Any of thefollowing on the ingredients labelof a soft drink indicates that thedrink has sugar added: glucose,glucose syrup, fructose,concentrated fruit juice, sucrose,dextrose, honey, invert sugar,maltose, hydrolysed starch.

Sweetened fizzy drinks such ascola or lemonade are both sugaryand acidic. The ‘diet’ versions ofthese drinks can also be harmfulto teeth even if they do notcontain sugar, as the acidityerodes the dental enamel.

Many ready-to-drink cartons ofsquashes, fruit drinks or fruitjuices have a high sugar contentand cannot be diluted if they aredrunk straight from the carton,and children who are regularlygiven full strength drinks maybecome used to the intensity ofthe sweetness. Children whobring their own drinks to childcare should be encouraged tobring a plastic flask or a liddedplastic cup containing anappropriately diluted drink.

Pure unsweetened (100%) fruitjuices

Pure fruit juices are a goodsource of vitamin C as well assome other nutrients. They aremost beneficial when given withmeals, as this may help the bodyabsorb iron. However, fruit juiceshave also been shown to beacidic enough to erode dentalenamel in young children so it isbest to avoid giving them

between meals and, when givingthem to under-5s, it is best todilute them with plenty of water.

Some fruit juice drinks areavailable which contain somefruit juice, with added sugar andwater. These are not a goodchoice for under-5s. Fruit juicedrinks which have been fortifiedwith a range of extra vitaminsand minerals are not suitable forchildren. Always check the labelto see if the drink is marked‘unsuitable for children’.

Water

Tap water is suitable for childrenand should always be the drinkof choice for quenching thirst.Some bottled waters may have ahigh content of salts, so cooledtap water is the best option. Ithas been reported that parentsand carers do not like givingwater to children as they thinkchildren will reject it, that it is‘cruel’, and that offering water isa sign of poverty.15 It is importanttherefore that carers are positiveabout water drinking, make surethat palatable water is alwaysavailable, act as role models forwater drinking, and encouragechildren to serve water to eachother. Children in child care mayenjoy having their own waterbottles to drink out of during theday. These should be clearlymarked with their name andrefilled daily with fresh, cooledtap water.

Other drinks

Tea and coffee are notrecommended as a drink forinfants or children as the tannicacid they contain reduces theabsorption of iron.16 However, itis recognised that some childrenin child care are given milky teaas a way of encouraging them todrink milk. If tea is used in thisway it should be very weak.

Tap water is suitable

for children and

should always be

the drink of choice

for quenching thirst.

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Which drinks to give

Drinks should be given in an open cup or beaker. Donot use feeder cups (sometimes called ‘dinky feeders’or ‘non-spill cups’) which children must suck on to gettheir drinks as sucking drinks across the teeth cancontribute to tooth damage and mimic the action ofdrinking from bottles. ‘Doidy’ cups (which have anaturally tilting front edge to make drinking easy forvery young children) are recommended by manyhealth professionals and can be obtained from theNational Childbirth Trust. (For details see Equipmenton page 86.)

• Encourage children to drink water if they are thirsty.Water quenches thirst, does not spoil the appetite,and does not damage teeth. Tap water is preferableas some bottled waters have a high content of saltsand may not be suitable.

• Promote milk as a drink in a cup. Whole cow’s milk issuitable as a main drink for most children from 12months of age. Semi-skimmed milk can beintroduced after the age of 2 years, provided thatthe child is a good eater. Skimmed milk is notsuitable as the main drink for a child under 5 yearsof age. Drinking too much milk is associated withpoor iron status. Up to about three-quarters of apint (around 450ml) of milk each day is likely to befine.

• Diluted fruit juice is a useful source of vitamin C.Children should be encouraged to have a glass ofdiluted fruit juice with their main meal or withbreakfast as this may also help the body to absorbiron (see page 32).

• Discourage children from having fizzy drinks andsquashes (including fruit squashes and fruit drinks),both diet and non-diet, as these can erode the toothenamel and contribute to tooth decay. Also, theyprovide little in the way of nutrients, and childrenwho drink them frequently may have less appetite toeat well at mealtimes.

• Tea and coffee are not suitable drinks for under-5sas they contain tannic acid which interferes with ironabsorption.

Dental health amongthe under-5s

The role of non-milk extrinsicsugars (NME sugars) in dentalhealth is described on page 23. Itis accepted that dental decay isdirectly related to the frequencyand amount of NME sugarconsumption.17 There is a popularmyth that it does not matter ifchildren have tooth decay in theirfirst teeth. This is not the case.Tooth decay in a child’s firstteeth:

• can affect the development ofthe permanent teeth

• can cause infections andswelling which can be painfuland lead to sleepless nights,and

• may involve the need to extractteeth under anaesthetic.

The incidence of dental diseasein young children in the UKdecreased dramatically in the1970s due to the introduction anduse of fluoride toothpastes butsince then reductions haveslowed down. In 2003, 40% of 5 year olds had some experienceof dental decay and 53% hadsigns of tooth surface loss causedby erosion.18 High intakes of softdrinks are likely to be directlycausative in both decay and toothsurface loss, and studies showthat children put to bed with asugary drink, those who brushtheir own teeth withoutsupervision, and those who usebottles for drinks are at greatestrisk.19

To reduce the risk of decay, it isimportant to reduce the amountof time that teeth are exposed tofoods high in non-milk extrinsicsugars. This includes foods suchas sweets, biscuits, cakes andsugary cereals as well as softdrinks. Fresh fruit is a goodchoice as a snack, but fruit juiceand dried fruit do containsignificant amounts of non-milk

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How carers can help reduce tooth decay inchildren • Reduce the total amount and especially the frequency of sugary foods

and drinks that children have.

• If children are having sugary foods and drinks, these should be given withmeals rather than between meals. This is because children’s first teeth areprone to decay if they are frequently in contact with sugars. Using a strawwith drinks may reduce the contact of the drink with the teeth.

• To help the healthy development of teeth, children should not be givensweet drinks (such as fruit juice, fruit juice drinks, squashes and other softdrinks) in a feeding bottle, dinky feeder or non-spill cup. An open cup orbeaker should be used if these drinks are given with meals.

• If a child uses a dummy or comforter, never dip it into sugar or sugarydrinks as this will contribute to tooth decay.

• Some soft drinks which claim to have ‘no added sugar’ still contain sugarswhich are harmful to the teeth. Diet drinks, both fizzy and still, can alsobe harmful to the teeth. This is because they may be acidic and erode thedental enamel, especially if sipped frequently. The use of these drinksshould be avoided or limited.

• Milk and water are the only safe drinks for children’s teeth. Flavoured milkswith added sugar should only be served with meals.

• It is generally not advised that children brush their teeth while in childcare but they should be encouraged to do this at home.

Additional advice for parents of under-5s

• Brush children’s teeth daily with a pea-sized blob of fluoride toothpaste.Children whose teeth are brushed by their parents or carers have lessplaque.21 Toothbrushing should be supervised by an adult for children upto 7 years of age. Children should spit out the toothpaste, but not rinsetheir mouths after brushing.

• Fluoride supplements can be given to children who are at high risk ofdental decay. Parents should ask their child’s dentist if this is necessary.

• Children should start visiting the dentist regularly by 3 years of age.(Dental check-ups and treatment are free up to the age of 18, or up to 19if they are in full-time education.)

• Choose sugar-free medicines where possible. If a GP is prescribingmedicines, the parent should ask the GP or pharmacist if a sugar-freeversion is available.

• Soft drinks such as fruit drinks and fruit squashes should never be given atbedtime or during the night as these are particularly associated withdental decay.

extrinsic sugars so they should beconsumed with meals rather thanbetween meals.20

Carers should ask parents andguardians the name and contactdetails of the child’s dentist whenthey register with them for childcare. This will help to prompt

them to register their child with adentist if they have not alreadydone so. NHS Direct will putparents in touch with an NHSdentist in their area. (For details,see page 85.)

Commercial foodsfor babies andchildren

There are a wide variety of babyand toddler foods available fromcommercial manufacturers, manyof which can be a useful choicewhen time or facilities for foodpreparation are limited. Whilethere are strict guidelinesensuring that baby foods sold forinfants (under 1 year of age) arenot too high in salt and that theydo not contain certain pesticideresidues,22 foods for under-1s areoften still high in sugars.

There are no similar guidelinesfor foods for children over 1 yearof age and many baby food‘snacks’, such as biscuits, sold assuitable for children over 1 arevery high in sugar. Intakes ofthese snack foods should betreated in the same way as forany equivalent adult foods. Carersshould look at food labelscarefully and choose baby foodsand snacks that are lower in saltand sugar. Baby foods are alsovery expensive and do not offergood value for money comparedwith home-made foods. For ideasfor snacks for under-5s, see page55.

Vegetarian diets

Children can get the energy andnutrients they need from avegetarian diet but a little extracare is needed. Nutrient-richfoods such as milk, cheese andeggs can provide protein, vitaminA, calcium and zinc but obtainingenough iron from a meat-free dietmay be more difficult. If the childeats fish, iron can be found inoily fish such as sardines,pilchards and tuna. Iron is alsofound in pulses such as beansand lentils, in dried fruit and inbreakfast cereals. The iron maybe more easily absorbed if the

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child has foods or drinks that arehigh in vitamin C – for examplefruits, vegetables or juices – at thesame meal. Tea and coffeeshould not be given as these caninterfere with the absorption ofiron. A vegetarian diet whichprovides a variety of cereal foods,vegetables, pulses, fruits anddairy products is likely to supplysufficient nutrients.

The vitamin drops obtained atchild health centres are suitablefor vegetarians but may not beacceptable to strict vegans as thevitamin D is sourced from sheep’swool. (For more on vitamindrops, see page 28.)

When cooking food forvegetarians who exclude fooditems for religious or ethicalreasons, it is important that thefood given is not compromised inany way. For example, pickingmeat out of a dish is notacceptable – the vegetarian dishshould be prepared first and themeat added later for otherchildren. Care should be takenwith ingredients such as gelatine,lard or suet, and labels should bechecked for animal fats andanimal rennet.

Information and advice oningredients to avoid can beobtained from the VegetarianSociety (see page 85).

Vegan diets

Vegan diets are outside the scopeof this report. Parents of veganchildren must take their ownresponsibility for their children’sdiets and can get advice from theVegan Society (see page 85).

Special diets

Some children have specialdietary requirements. Special dietsare the foods recommended by aregistered dietitian or doctor for aspecific medical condition.Children with coeliac disease for

example cannot tolerate gluten,the protein in wheat flour as wellas in a number of other cerealsincluding barley and rye, andthey require a gluten-free diet. Ifa child has a recognised specialdiet, the parent or guardianshould be able to supply a list ofacceptable foods, and in somecases can provide the foodsthemselves. A careful plan forchoosing a safe and nutritiousdiet for the individual child needsto be drawn up in consultationwith a registered dietitian.

Dairy-free diets

Dairy-free diets may be necessaryfor children who are lactoseintolerant or have a cow’s milkprotein intolerance.

Lactose is the sugar naturallyoccurring in milk and all milk-based foods. Lactose intoleranceis commonly found in someAsian and African populations. Itis caused by a deficiency oflactase – the enzyme required todigest lactose – and it causesunpleasant digestive symptomsincluding diarrhoea.

Some children may be intolerantto cow’s milk protein. One studyon the Isle of Wight showed thatcow’s milk intolerance was foundin 4.4% of children aged 1 year,1.9% of children aged 2 years,and 0.4 % of children aged 4years.23

Milk and other dairy foodsprovide a substantial amount ofcalcium, iodine and riboflavin inthe diets of children. Infants andchildren up to 2 years who donot have milk or dairy productsshould continue on the infantformula recommended to themby a doctor or a registereddietitian. After the age of 2, ifsoya products are acceptable,children can be given a soyadrink which has been fortifiedwith calcium (found by checking

the label). Other sources of non-dairy calcium are soya-basedfoods such as tofu, tempeh andsoya mince or soya cheese, soyadrink fortified with calcium,canned sardines or salmon(including the bones), pilchards,egg yolk, bread, breakfast cereals,pulses (such as beans, lentils andchick peas), dark green leafyvegetables, sesame seeds, sesamepaste, ground almonds and driedfruit.

The parent or guardian should beable to provide a list of foodswhich are milk-product-free.

Food allergy

Food allergy can be defined as areproducible adverse reaction to afood involving the immunesystem. In food allergy there is anabnormal sensitivity to asubstance present in food(usually a protein) which isgenerally considered harmless forthe majority of people. Reactionscan be severe and in rare caseslife-threatening, but most peoplegrow out of food allergies inearly childhood.

Chilcare settings should have anallergy plan in place. Informationfor pre-school settings on how tomanage allergic children can befound onwww.allergyinschools.org.uk.

Foods that can cause severeallergic reactions include:peanuts, nuts, shellfish, sesameseeds, cow’s milk, eggs, fish,citrus fruits, soya beans, wheatand other cereals. Food allergiesare more likely to occur inchildren with a family history ofallergies such as asthma, eczemaor hay fever.

While many parents believe thattheir children are sensitive tocertain foods, the true incidenceis likely to be very much lowerthan reported. Parents requesting

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special diets for their childrenbecause of food allergy should beencouraged to seek advice from adoctor or a registered dietitian ifthey have not already done so. Itis unwise to restrict food choiceamong young children withoutappropriate help and advice.

However, it is important to notethat a Department of HealthExpert Panel recommends that, inchildren with a family history ofatopic disease (asthma, eczema,hay fever or food allergy),peanuts and peanut productsshould be avoided until the childis 3 years old.24 For children whoare advised to avoid nuts infoods, careful checking of foodlabels will be required. Newlabelling regulations require thatwhenever certain allergenicingredients (including tree nutsand peanuts) or products derivedfrom them are used in pre-packed foods, the label mustclearly indicate that they arepresent in the food.25 For thosechildren who are advised toavoid nuts in foods, theseingredients can be identified bylooking carefully at theingredients of pre-packed foods.

The following are some of thenames given to nuts or nutproducts: nuts, chipped nuts,flaked nuts, peanuts, groundnuts,monkey nuts, earthnuts, arachis

hypogaea, arachis oil, groundnutoil, peanut oil, peanut butter, nutbutters, nut paste, marzipan,praline, frangipane, goober peas,pinder, goober, nut flavours, nutextract, hydrolysed vegetable oilsor proteins, nut oil derivatives oradditives such as E471, E472 orlecithin. Foods purchased withoutlabels (for example food boughtunpackaged in shops or fromopen markets) should always betreated with caution.

Diet, behaviour andlearning in children

There is significant currentinterest in whether the diet caninfluence children’s behaviourand ability to learn andconcentrate. Overall, research inthis area suggests that a good,varied diet is the best way toensure optimal mental andbehavioural performance inchildren, and that only thosechildren who have very poornutritional status (for example,those with severe iron deficiencyanaemia) may benefit fromdietary manipulation.26 There isinsubstantial evidence that givingchildren fish oil supplementsimpacts on their performance.Ensuring that the diet is of goodquality should be a priority ratherthan buying expensive nutrientsupplements.

Children with specialneeds

Children with special needs andphysical disabilities shouldwhenever possible beencouraged to eat the samehealthy diet in the same way asall other children. When planningfood provision and menus, carersneed to consider any children intheir care who have special needsso that they can feel included at

meal and snack times. Somechildren may have particulardietary requirements or may needspecific help with eating, both ofwhich are outside the scope ofthis report. Advice can beobtained from a registereddietitian. Parents or guardians andcarers may also find it useful tocontact support groups associatedwith the child’s particulardisability or need.

Food safety andgood hygiene

Food provided to under-5sshould be stored, prepared andpresented in a safe and hygienicenvironment. Extra care is neededfor infants and young children asthey may have a lower resistanceto food poisoning.

Carers should always wash theirhands with soap and waterbefore preparing food or helpingchildren to eat, and afterchanging nappies and toiletingchildren. If carers use ahandkerchief while preparingfood, they should wash theirhands before continuing.

All work surfaces and utensilsused in the preparation of foodshould be clean.

Carers need to be aware of therequirements of the Food SafetyAct. Some carers may need tocomplete a Food HygieneCertificate course. Furtherinformation on this can beobtained from the localauthority’s environmental healthdepartment, or from itsregistration and inspection unit.

Carers also need to be aware offood hygiene and food safety toprevent food contamination andfood poisoning. They need toknow about storage of food andleftover food, and thoroughcooking or heating of foods.Several useful publications are

Ensuring that the diet

is of good quality

should be a priority

rather than buying

expensive nutrient

supplements.

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available from the Food StandardsAgency (see Appendix 5). Carersshould obtain these and followthe advice in them. Some of themain points for carers are givenin the box below.

It is also important that childrenare taught basic hygienethemselves – for example noteating food that has fallen on thefloor, and washing their handswith soap and water before

Food safety and hygiene hints • Do not leave perishable food at room temperatures for more than 2

hours. Perishable food brought from home, including sandwiches, shouldbe kept in a fridge or cool place below 8oC.

• Insulated cool boxes, or a cool box with cool packs, should be used forcarrying food when taking children on trips or outings.

• Eggs should be kept in the fridge.

• Eggs given to babies or toddlers should be cooked until both the yolk andthe white are solid.

• Food stocks should be rotated and food beyond its use-by date discarded.

• If food is to be eaten warm it should be re-heated until piping hot (70oC)for 2 minutes and then cooled down before serving.

• Avoid keeping food hot for long periods.

• Cool leftover food quickly, cover and refrigerate, ideally within 1-2 hours.

• Do not use unpasteurised milk, or milk-based products such as cheeseand yoghurt made from unpasteurised milk. If a parent brings in goat’s orsheep’s milk for their child, check with the parent if the milk needs to beboiled.

• Root vegetables such as carrots and parsnips should always be peeled andtopped and tailed. Fruit and vegetables to be eaten raw should be peeledfor very young children, and washed well.

• Whole pieces of nut should not be given to under-5s in case of choking.Ground nuts and chopped nuts can be included in foods for under-5swhere appropriate.

• Allergic reactions can be very serious. There should be a careful plan forchoosing a safe and nutritious diet for any individual child with a trueallergy.

General safety issues

• Children under 5 should never be left alone while they are eating, in casethey choke.

• All highchairs should be fitted with a safety harness which should be usedat all times when children are in the chairs. Children should never be leftunsupervised while in a highchair.

For information on food safety and hygiene issues for infants, see page 43.

eating meals or snacks and aftergoing to the toilet or handlinganimals.

Pets should not be allowed nearfood, dishes, worktops or foodpreparation areas.

Eating patterns andtiming of meals andsnacks

The eating patterns of many pre-school children are erratic andfood faddiness is common.Children at this age becomerapidly disgruntled when hungryand are likely to require snacks inbetween their main mealtimes.

If children in child care are givensnacks either at inappropriatetimes or inadequately, they maybe ravenous when picked up bytheir parents or guardians. Theymay then fill up with snack foodson the way home, which do notprovide the same nutritionalbenefit as a main meal. Carersand parents or guardians maywish to discuss the mostappropriate times for afternoonsnacks and tea so that this can beavoided.

Breakfast

Children who are cared foroutside the family home mayhave less time for breakfast athome and may benefit from ameal similar to breakfast withtheir carer. Breakfast cerealsserved with milk make animportant contribution to dailynutrient intakes. The bestbreakfast cereals for children arethose which do not have sugaradded and which are oftenfortified with minerals andvitamins (particularly iron) – forexample corn flakes, crisped rice,puffed wheat or wheat bisks.Higher fibre cereals (such aswhole grain or bran cereals)should be given in moderation asthey are bulky and may fillchildren up quickly. Cereals (suchas muesli) which contain wholenuts should not be given to theunder-5s. Carers should look forbreakfast cereals which are lowin salt and sugar.

It is important that children have

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Ideas for nutritious snacks • Dairy foods such as cheese or plain yoghurt with added fruit

• Fresh fruit such as pears, apple slices, satsumas, banana, seedless grapes,slices of melon, mango, pineapple, kiwi, plums (without stones), or berriessuch as strawberries and raspberries. Choose fruits in season and thosethat are grown locally where possible. The fruit from canned fruit in juicecan be used in fruit kebabs or added to yoghurt or fromage frais.

• Raw vegetables such as peeled carrots, sweet pepper, tomato, cucumberor celery (all well washed) with dips such as houmous or Greek yoghurtwith chives

• Home-made plain popcorn

• Plain biscuits such as crispbreads, oatcakes, breadsticks, cream crackers,matzos, rice waffles, melba toast. Some of these foods can be high in salt,so choose those that have less than 0.5g sodium per 100g where possible

• Any type of bread (use a variety of white, brown, wholemeal, granary orcrusty breads, including toast); crumpets, English muffins, bagels, pittabread or sandwiches. Look for lower-salt (low-sodium) versions whereavailable. Suitable fillings for sandwiches might be meat (for example,cold roast meats, chicken, ham, corned beef, meat paste), cheese,cottage cheese, fish paste, mashed pilchards or sardines, tuna, egg,houmous, roast vegetables, banana, salad or combinations of these.

Ideas for nutritious snacks are also included in the sample menus given inchapter 6.

breakfast. Parents and guardiansshould work together with carersto ensure that children havebreakfast, either at home or whenthey arrive in child care.

Timing of meals and length ofmeals

Children need to eat regularly.Carers planning the timing ofmeals and snacks should ensurethat they are spaced outappropriately throughout the day,so that, for example, children donot have a long gap betweenlunch and tea, or between teaand when they go home.

Some children may eat slowly. It is important to ensure that allchildren have enough time to eat.In some European countries thereis a recommendation for theamount of time that should beallowed for meals in nurserysettings which seems to varybetween 30 and 45 minutes.27

Snacks

Children need nutritious snacksbetween meals. The best snacksare those without added sugarbut which offer a range of othernutrients. A variety of snacksshould be offered including fruit,vegetables and any type of breadsuch as sandwiches, yoghurts,dips and other savoury foods (seeIdeas for nutritious snacks,below). It is best to avoid givingsweets, sweet biscuits, cakes,sugary or fizzy drinks and driedfruit and fruit juices as snacks ontheir own: keep these foods anddrinks to mealtimes only.

How carers canencourage eatingwell

To help develop social skills, it isgood practice for carers to sitwith children when they are

eating and (where appropriateand if they can), eat the samefoods and drink the same drinks.An encouraging and pleasantenvironment is important at mealsand carers provide an importantpositive role model.28 In thesame way as carers should notsmoke in front of children, theyshould also set a good examplein the foods and drinks theychoose for themselves.

A meal is a time for eating but itshould also be a time forsocialising and learning. Childrencan learn from the carer abouttable manners, and can practisetheir speaking and listening skills.To encourage this, distractionssuch as television should beavoided during mealtimes. Allchildren should be encouraged todo whatever they can forthemselves in terms of eating, tohelp them develop skills andindependence. Encouraging goodtable manners and social skillsaround eating are an importantpart of a child’s development.

Language development is fosteredwhen children interact in smallgroups, and carers should sit andchat with children during mealsand snacks. Children also enjoybeing involved in mealpreparation, table setting andclearing away.

Rewards are often given tochildren as a way of encouraginggood behaviour or if they havedone well in a particular task.Rather than giving sweets,chocolates and sweet snacks suchas biscuits to reward goodbehaviour, rewards can be givenin the form of smiles and praise(‘soft rewards’) or as smallinexpensive items such as stars,stickers or badges (‘hardrewards’). Most children are veryhappy with soft rewards andenjoy getting praise or attention.Older children are more likely tobe influenced by hard rewardsbut a simple stamp on the handwith washable ink (for example

56


in the shape of a teddy) willallow the child to see and sharetheir ‘reward’ with parents andguardians.

There is nothing wrong withgiving children sweetsoccasionally and children willoften receive them as tokens ofaffection or to celebrate specialevents such as Easter, ChineseNew Year or Diwali. It is best togive sweets after a main mealrather than between meals asthey will do the least damage toteeth at this time and will notspoil the child’s appetite.

Making the most ofmealtimes • Sit with the children during

meals and snacks.

• If the carer eats at the sametime as children, it is importantthat what the carer eats anddrinks provides a good rolemodel for healthy eating.

• Avoid distractions such astelevision.

• Do not hurry children as theyeat.

• Encourage children to try all thefood offered to them.

• Encourage good table manners.

• Do not force children to eat allthe food offered.

• Chat to the children during themeal.

• Use the mealtime as anopportunity to provideeducation about healthy eating.

• Respect the behavioural normsand expectations of specificcultures.

Adapted from Nahikan-Nelms, 1997. 5

Tips for tackling foodrefusal • Gently encourage children to eat

but if a child refuses to eat, takeaway the food without passingjudgement.

• Praise children when they eatwell.

• Eat with children and makepositive comments about thefood.

• Give small portions. Seconds canalways be given.

• Develop a clear routine of mealsand snacks, avoiding drinks andsnacks close to mealtimes.

• Offer a variety of tastes andtextures at meals.

• Make sure the eatingenvironment is calm and relaxed.

• Involve children in shopping,cooking and planning meals.

Dealing with foodrefusal

Periods of fussy eating amongunder-5s are not unusual.Children should be allowed tomake their own food choices. If achild refuses a food or meal, thecarer should gently encouragethem to eat, but children shouldnever be forced to eat. Tominimise food refusal, it isimportant to ensure that a varietyof foods are offered. Toddlersmay be wary of trying new food(neophobia) and this may alsoinclude rejecting foods that theydo normally eat if the foods areserved in different shapes andsizes or containers.29 Sometoddlers are more neophobic thanothers and it has been reportedthat vegetables, fruit and meat aremore likely to be rejected bythese children.30

If a child refuses a food evenafter gentle encouragement to eat,remove the food without makinga fuss or passing judgement.While it is useful to encouragechildren to try different foods, itis not good practice to rewardchildren for eating food they donot want (particularly by offeringthe reward of pudding or a sweetsnack). Words of praise andencouragement to try foods andeat a variety of foods may helpsome children at mealtimes. Itmay be useful to adopt theapproach that a food refused is‘not liked today’. Food fads oftendo not last more than a couple ofweeks and children may, atanother time, accept a food thatwas previously rejected. It isimportant that a good variety offoods are continually offered.

While it can be distressing forcarers (and parents or guardians)to have food they have preparedrejected, keeping your ownattitude to eating friendly andrelaxed will help children to feelthat eating is a pleasurable way

to satisfy hunger rather than abattleground.

A child’s opinion about what theylike and dislike should berespected and it is better not to‘disguise’ foods that they haverejected. However, changing theform a food is given in maymake the food more acceptable.For example, a child might refusecooked carrots but enjoy rawones, or may refuse pasta coatedin sauce but prefer the pasta andsauce served separately.

Learning throughfood

Child care provides theopportunity for children to learnabout food, food sources,nutrition, health, the seasons,growing cycles and otherpeople’s ways of life. Learninghow to choose and enjoy manydifferent nutritious foods in early

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Food-related activities • Making pictures with food – for

example, using dried pasta andpulses, rice, seeds or bay leaves

• Cutting out food pictures frommagazines for collages, murals ormobiles

• Food prints: halved smallpotatoes, carrots, apples orparsnips

• Making a seed ball for the birds

• Papier maché fruit andvegetables

• Growing mustard and cress orsprouting seeds

• Making playdough or salt dough

• Having a pretend café or shop

• Food tasting

• Food smells game – for examplespices, vinegar, orange, onion,strong cheese

• Food-related songs and rhymes –for example: Five currant buns,Five little peas in a pea-podpressed, Mix a pancake, Ten fatsausages.

Carers should positively encourageboth boys and girls to participate inall activities, including food-relatedactivities such as cooking.

Resources for encouraging learningthrough food-related activities canbe found in Appendix 5.

childhood can provide thefoundation for a lifetime of wisefood choices.31 Research suggeststhat even very young children areready to learn more about food,nutrition and health thanpreviously thought.32

Activities involving food willencourage children both todevelop a range of skills and toincrease their knowledge of food.They will also give children theopportunity to learn about newand different foods, and foodsfrom a variety of cultures shouldbe included, particularly those

represented in the place of childcare.

Carers can also involve childrenin preparing food and laying andclearing tables. This will allcontribute to their educationalexperience.

Listening to children

It is important to listen to, andconsult with, the children inchildcare settings about thechoices of foods on offer.Research has shown that pre-school children often want morechoice of food and are pleased tobe consulted on menu planning.33

Carers have an important role inlistening to children and helpingthem learn through example.Examples of how carers candevelop their skills in listeningand responding to young childrenaround food and food-relatedactivities can be obtained fromthe National Children’s Bureaupublication Listening andResponding to Young Children’sViews on Food.34

Involving andlistening to parentsand guardians

It is important to involve parentsor guardians in encouraginghealthy eating and to listen totheir concerns and ideas.Evidence suggests that in manychildcare settings there is a lackof partnership between parentsand carers on the practicalities offood provision.35 It may be thatparents and carers lackunderstanding of the other’s rolein food provision, with bothbelieving that it is theresponsibility of the other toprovide the nutritiouscomponents of the diet such asfruit and vegetables. A realpartnership between carers and

parents and guardians should befostered to ensure that each hasthe opportunity to communicatetheir concerns to the other. Thiscould include:

• Meeting with parents orguardians and making sure theyare aware that the carers arecommitted to providing healthy,varied (and enjoyable) food.

• Making menus available toparents, for example bydisplaying them on anoticeboard, or where childrenleave their coats. This will helpfamilies to plan a diet which isbalanced between the childcaresetting and home. Carers couldalso ask parents for suggestionsfor menu items.

• Giving parents adequate noticeof any changes to meals, foodchoice or any other aspect offood provision, and allowingthem to comment on anddiscuss the changes before theyare introduced.

• Giving parents or guardiansclear information each dayabout what food has beeneaten and if their child haseaten well. Even older childrenmay not be accurate inreporting what they have eaten.

• Inviting parents and guardiansto share special foods andrecipes with carers. Carersshould seek advice fromparents and guardians if theyare serving food which thecarers themselves are notfamiliar with. Such food shouldnot only contain the rightingredients but should look andtaste right too.

Carers should ask parents orguardians about any specialdietary requirements their childhas before the child startsattending the childcare setting.Parents or guardians of childrenwho are on special diets (forexample a gluten-free diet) orwho have food allergies areresponsible for providing the

58


carer with information about thefood choices available to theirchild. Parents or guardians shouldtalk to their GP or health visitorfor help and advice. The GP mayrefer the family to a registereddietitian. In some cases, the carermay want to insist that the parentor guardian provides the child’sfood, for example for children onvegan diets.

Bringing food fromhome

In some cases children may bringfood from home to eat while theyare in child care. It is helpful ifthe childcare setting has its ownnutrition policy (see the exampleon page 59). This can be given toparents to help them in choosingand preparing food they sendfrom home. It is reasonable toask that children who bring foodfrom home have similar foodchoices to the children who mayhave food provided for them inchild care, particularly for snacks.A nutrition policy could request,for example, that children do notbring packets of crisps orconfectionery with them. It isadvisable to discuss these issueswith parents when they areorganising their childcare orbefore changes are introduced.

Food for specialoccasions

Food is often eaten to celebratespecial occasions. For example,sharing a birthday cake may bean important social activity.

Foods given as treats at home tomark special occasions are oftenbased around sweets, cakes andbiscuits and there is nothingwrong with the occasional treat.Where a large number of childrenare cared for together, however,there may be so many birthdays

January

Late January/early February

February

Late February/early March

March

March/April

May

Late May/June

August

September/early October

October/November

November

December

1st: New Year6th: Epiphany: Three Kings Day7th: Rastafarian New Year25th: Burns’ Night

Chinese New Year Jewish New Year for Trees

3rd: Japanese bean scattering14th: Valentine’s Day40 days before Easter: Pancake Day (ShroveTuesday)

Caribbean CarnivalChinese Festival of LightPurim (Jewish)

17th: St Patrick’s DayBaha’i New YearHoli (Hindu Harvest Festival)

Mothering SundayPassover (Jewish festival of Pesach)Easter

1st: May DayWesak: Buddhist festival, first day of fullmoon in May

Shavuot: Jewish Festival of WeeksTuan Yang Chieh: Chinese Dragon BoatFestival

Raksha Bhandhan: Indian celebration ofbrotherly/sisterly love

Jewish New Year: Yom KippurChinese Kite Festival Harvest Festival

31st: HalloweenDiwali: Hindu Festival of Light

5th: Guy FawkesThanksgiving

6th: St NicholasHanukkah (Jewish Festival)25th: Christmas Day26th: Boxing Day

Some of the most common festivals andcelebrations throughout the year

Festivals such as Eid-ul-Fitr, the Islamic festival of fast-breaking linked toRamadan, occurs at a different time each year: parents will be able toadvise carers on these dates. For a current calendar of religious festivalscontact the SHAP Working Party (address on page 86).

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and other special occasions (forexample Christmas, Easter,Diwali, Eid-ul-Fitr, Halloween,Chinese New Year, or birth ofnew brothers and sisters) that it isalmost a daily event. Carers maytherefore wish to think of otherspecial ways of celebrating. Thechildren are also likely tocelebrate outside of their childcare so are unlikely to miss outon special foods. Decorating theroom with balloons andstreamers, encouraging childrento dress up or wear party hats,playing party games andpresenting foods in interestingshapes can make a party withoutthe need for sweets, crisps,biscuits and cakes. A birthdaycake made out of play doughwith real candles will allow theritual ‘blowing out’ of the candlesto make the birthday child feelspecial.

Holidays, festivals and religiousoccasions of various culturesprovide a valuable opportunity toinclude special occasion food andto involve the parents. The mix ofchildren being cared for willdetermine which festivals inparticular are celebrated, but it isimportant for children to learnabout and celebrate occasionsand cultures not representedamong them too. These eventsprovide a springboard for all sortsof activities, not just those relatedto foods, and are an importantpart of early years learning.

If parents wish to provide specialtreats for the children to helpcelebrate these occasions, letthem know what your policy isfor food for special occasions andfestivals so that they know whatto send in. Care should be takenwhen sharing foods that have notbeen prepared in the childcaresetting as the ingredients usedwill not be known. Carers needto be aware if any of the childrenin their care have a food allergy,so that they can ensure that thesechildren do not come into contact

Sample nutrition policy • The weekly menu will be on display in advance. Recipes will be available to

parents.

• The weekly menu will provide children in child care with a tasty, varieddiet.

• All the children in child care will have suitable food made available forthem.

• Children who do not receive breakfast at home will be offered this whenthey arrive, if this is agreed with parents or guardians.

• Milk will be served with morning and afternoon snacks.

• Soy milk drinks will only be given as a substitute for cow’s milk with theparent’s agreement and then only those fortified with calcium will begiven.

• Water will be available at all times.

• Diluted fruit juice will be served with the main meal.

• Children will be allowed to have second helpings of fruit or milk-baseddesserts.

• Children will still receive dessert if they refuse their main course.

• Sweets and soft drinks will not be served.

• Parents or guardians will be advised if their child is not eating well.

• Parents of children who are on special diets will be asked to provide asmuch information as possible about suitable foods and in some cases maybe asked to provide the food themselves.

• A specific allergy plan will be in place to deal with any child having anallergic reaction.

• Carers will sit with children while they eat and will provide a good rolemodel for healthy eating.

• Withholding food will not be used as a form of punishment.

• Children will be encouraged to develop good eating skills and tablemanners and will be given plenty of time to eat.

• Advice will be given to parents about suitable foods to bring from home.

• Children will be encouraged to play outside every day, weather permitting.This will ensure that they have an opportunity to be exposed to summersunlight which helps their bodies to make vitamin D.

Developing anutrition policy

The best way to make sure thatthe recommendations and advice

with any foods they might beallergic to.

The box on page 58 shows acalendar of many of the mainannual events.

about healthy eating are agreedbetween the carer(s) and parentsor guardians is to write anutrition policy. This is not asdifficult to do as it may sound:many childcare settings alreadyhave a lot of ‘unwritten’ rulesabout food and eating. Theadvantage of writing them downas a ‘policy’ is that everyone hasa chance to agree these ideas andin addition they provideinformation to new parents aboutyour approach to healthy eating.

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References1 Dowler E, Calvert C. 1995. Nutrition and Diet

in Lone Parent Families in London. London:Family Policy Studies Centre.

2 Kant AK, Schatzkin A, Harris TB, Ziegler RG,Block G. 1993. Dietary diversity andsubsequent mortality in the First NationalHealth and Nutrition Examination SurveyEpidemiologic Follow-Up Study. AmericanJournal of Clinical Nutrition; 57: 434-440.

3 Story M, Brown JE. 1987. Do childreninstinctively know what to eat? The studies ofClara David revisited. New England Journal ofMedicine; 316: 103-106.

4 Birch LL, McPhee L, Shoba BC, Pirok E,Steinburg L. 1987. What kind of exposurereduces children’s neophobia? Appetite; 9:171-178.

5 Nahikan-Nelms M. 1997. Influential factors incare-giver behaviour at meal-times: a study of24 child care programs. Journal of theAmerican Dietetic Association; 97: 505-509.


Years. Volume 1: Report of the Diet andNutrition Survey. London: HMSO.

7 Attree P. 2005. Low-income mothers,nutrition and health: a systematic review ofqualitative evidence. Maternal and ChildNutrition; 1: 227-240.

8 www.fiveaday.nhs.uk

9 Wardle J, Cook LJ, Gibson EL, Sapochnik M,Sheiham A, Lawson M. 2003. Increasingchildren’s acceptance of vegetables: arandomised trial of parent-led exposure.Appetite; 40: 155-162.

10 Department of Health. 2004. At Least Five aWeek. Evidence on the Impact of PhysicalActivity and its Relationship to Health. AReport from the Chief Medical Officer.London: Department of Health.

11 Jago R, Baranowski T, Baranowski JC,Thompson D, Greaves KA. 2005. BMI from 3-6 years of age is predicted by TV viewing andphysical activity not diet. International Journalof Obesity; 29: 557-564.

12 To obtain a copy of Nursery Milk Guide: ForProviders of Day Care for Children Under 5.(2003), write to: WRFU, PO Box 31048,London SW1V 2FF. Tel: 020 7887 1258.

13 Hourihane JO’B, Rolls CJ. 1995. Morbidity fromexcessive intakes of high energy fluids: thesquash drinking syndrome. Archives ofDisease in Childhood; 72: 141-143.

14 Watt RG, Dykes J, Sheiham A. 2000. Preschoolchildren’s consumption of drinks: implicationsfor dental health. Community Dental Health;17: 8-13.

15 Chestnutt IG, Murdoch C, Robson KF. 2003.Parents’ and carers’ choice of drinks forinfants and toddlers in areas of social andeconomic disadvantage. Community DentalHealth; 20: 139-145.

16 Watt RG, Dykes J, Sheiham A. 2000. Drinkconsumption in British preschool children:relation to vitamin C, iron and calciumintakes. Journal of Human Nutrition andDietetics; 13: 13-19.

17 Hinds K, Gregory J. 1995. National Diet andNutrition Survey: Children Aged 11/2 to 41/2

Years. Volume 2. Report of the Dental Survey.London: HMSO.

18 Department of Health. 2005. Children’s DentalHealth in the United Kingdom 2003. London:TSO.

19 Harris R, Nicoll AD, Adair PM, Pine CM. 2004.Risk factors for dental caries in young children:a systematic review of the literature.Community Dental Health, 21, (1 suppl): 71-85.

20 Moynihan P. 2003. Fruit juice and dried fruit –healthy choices or not? Letter in the BritishDental Journal; 194: 408.

21 Habibian M, Roberts G, Lawson M, Stevenson R,Harris S. 2001. Dietary habits and dental healthover the first 18 months of life. CommunityDentistry and Oral Epidemiology; 29: 239-246.

22 European Union Directive. 2005. ProcessedCereal-based and Baby-foods for Infants andYoung Children Regulations 2004.

23 Dean T. 1997. Prevalence of allergic disorders inearly childhood. Pediatric Allergy andImmunology; 8 (suppl 10): 27-31.

24 Department of Health. 1998. Report on PeanutAllergy. Committee on Toxicity of Chemicals inFood, Consumer Products and theEnvironment. (COT). London: TSO.

25 Food Standards Agency. 2004. Food LabellingRegulations (Amendment No 2). Accessed fromwww.food.gov.uk/multimedia/pdfs/allergenukguidance.pdf

26 Bellisle F. 2004. Effects of diet on behaviourand cognition in children. British Journal ofNutrition; 92; suppl 2: S227-S232.

27 Children in Europe. 2006. An Appetite for Life:Young Children, Food and Eating. Accessedfrom www.childrenineurope.org

28 Birch LL. 1980. Effects of peer models’ foodchoices and eating behaviours on preschoolers’food preferences. Child Development; 51: 489-496.

29 Addessi E, Galloway AT, Visalberghi E, Birch LL.2005. Specific social influences on theacceptance of novel foods in 2-5 year oldchildren. Appetite; 45: 264-271.

30 Cooke L, Wardle J, Gibson EL. 2003.Relationship between parental report ofneophobia and everyday food consumption in2-6 year old children. Appetite; 41: 205-206.

31 Singleton JC, Achterburg CL, Shannon B. 1992.The role of food and nutrition in the healthperceptions of young children. Journal of theAmerican Dietetic Association; 92: 67-70.

32 Anliker JA, Laus MJ, Sammonds KW, Beal VA.1990. Parental messages and the nutritionawareness of preschool children. Journal ofNutrition Education; 22: 24-29.

33 Mooney A, Blackburn T. 2003. Children’s Viewson Childcare Quality. London: Department forEducation and Skills.

34 McAuliffe AM, Lane J. 2005. Listening andResponding to Young Children’s Views onFood. London: National Children’s Bureau.

35 Moore H, Nelson P, Marshall J, Cooper M,Zambas H, et al. 2005. Laying foundations forhealth: Food provision for under 5’s in day care.Appetite; 44: 207-213.

A nutrition policy should not beseen as something set in stone,but something open to regularreview.

A sample nutrition policy is givenon page 59 as a guide to the sortof information that you may wishto include.

Healthy eatingawards

In some areas of the country,healthy eating awards have beenestablished to encourage betterfood and drink provision in earlyyears settings. One example ofthis is the Under-5s HealthyEating Award set up byBedfordshire dietitians and oralhealth promoters. Over 100childcare settings and 50childminders have obtained anaward which means that theyhave received appropriate stafftraining and have met targets onthe food served at meals, thesocial aspects of eating anddrinking, food safety andhygiene, dental registration, useof suitable dining and eatingequipment, managingcelebrations appropriately andliaising with parents. For moreinformation about this scheme,contact [email protected].

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Chapter 6 Nutritional guidelines and menu planning

In this chapter, recommendations – in the form of‘nutrient-based standards’ – are made for theamount of energy and nutrients, and some foods,that should typically be provided for a group ofchildren aged under 5 who receive meals andsnacks in child care or other early years settings.This chapter also gives some recommendations formenu planners on how to put together varied andinteresting menus, and shows three examples ofmenus which meet the nutrient-based standards.

Why nutrient-basedstandards are themost effective wayto improve menuplanning

Nutrient-based standards specifythe amounts of nutrients, andsome foods, that should beprovided to a group of peopleover a period of time to ensurethat the nutritional needs ofeveryone in that group are met.They are based on the DietaryReference Values for Food Energyand Nutrients for the UK 1 andother appropriate guidance whichaims to promote good healththrough good food and drinkchoices. Nutrient-based standardsprovide a numerical but flexibleframework to help menuplanners put together variedmenus that are suitable for thepeople they serve.

To use nutrient-based standardseffectively requires simple toolswhich can also act as a trainingtool for those who plan menus orprovide food for others. TheCaroline Walker Trust produced acomputerised menu planner toolin 2001 (CHOMP) which allowedmenu planners to put together,easily and quickly, menus whichmeet nutrient-based standards forunder-5s from a detailed databaseof foods and drinks. This hasbeen extensively used in the earlyyears sector and evaluation hassuggested that using nutrient-based standards is neitheronerous nor complicated forproviders if appropriate tools areprovided. A new updatedcomputer tool to work with thestandards for under-5s in thisreport is currently beingproduced and details can befound on the Caroline WalkerTrust website www.cwt.org.uk.

Menu planners should ensure thatany menu analysis software they

Eggs, peas, bread and carrotsImogen, aged 4

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use is based on nutrient valuesfor cooked foods and recipes andthat, where the software has notbeen specially prepared forplanning menus for under-5s,necessary help with analysis isprovided by a registered dietitianor registered public healthnutritionist.

Nutrient-based standardsencourage transparency amongall stakeholders as thecomposition of foods, recipes andingredients used in menus areclear and confusions that canarise from food-based standardsbetween similar food productsare avoided. Nutrient-basedstandards also allow goodpractice to be shared and make itpossible to monitor theimplementation of standards andcarry out an on-going evaluationof how standards are being metand where extra support isneeded.

In addition, adopting nutrient-based standards, and providingthe necessary tools and supportfor those who provide food forunder-5s in the UK, sends a clearmessage that policy makers takethe promotion of good nutritionseriously.

All those who inspect childcareservices in the UK should monitorthe nutritional standards of thefood served in the childcare andother early years settings theyvisit. Inspectors’ reports shouldinclude comments on food andnutrition. Any childcare settingthat does not meet the standardsshould seek advice from aregistered dietitian or registeredpublic health nutritionist.

How the nutrient-based standards havebeen calculated

Children have different needsdepending on their age andgender, and the requirements ofevery child will be different. Therecommendations thereforerepresent average intakes. If thefood offered to a group ofchildren provides the amount ofnutrients recommended, and thechildren receive the balance oftheir requirements at home, thenthe nutritional needs of mostmembers of that group are likelyto be met. The recommendationsare not designed for individualsbut act as a framework for menuplanners and those advisingmenu planners on appropriatediets.

The recommendations are basedon percentages of the total dailyintake of nutrients required by an‘average’ child in a group of 1-4year olds, or a group of 1-2 yearolds, or a group of 3-4 year olds.Children will spend differentperiods of time in child care andthe recommendations considerthe needs of:

• 1-4 year olds in full-day or half-day child care, or for thosehaving individual meals andsnacks while in child care

• 1-2 year olds in full-day or half-day child care, or for those

having individual meals andsnacks while in child care, and

• 3-4 year olds in full-day or half-day child care, or for thosehaving individual meals andsnacks while in child care.

It is recommended that the foodprovided in full-day child careshould give children 70% of theirrequirements for energy and mostother nutrients.

The recommendations apply tochildren who attend all forms ofchild care including playgroups,nursery units and receptionclasses, and are based on averageDietary Reference Values for boysand girls.

The derived nutrient values fromwhich the nutrient-basedstandards have been calculatedare given on page 82.

Standards for particularnutrients

FatThe current advice for adults andchildren over 5 years is toconsume a diet in which about35% of their daily energy needsare provided by the fat in foodand added to food. It hasgenerally been suggested that thefat intake of children aged under2 years should not be restricted,as the under-2s need foods whichare energy-dense and nutrient-dense – that is, foods which packa lot of calories and othernutrients into a small amount offood. However, evidence from alarge longitudinal study ofchildren at 18 months suggeststhat there is no evidence thatchildren who get 30-35% of theirenergy from fat experiencedelayed growth, and there is infact evidence that children whoget 39-43% of their energy fromfat may have lower intakes ofiron and vitamin C and loweriron status.2 It has also beenreported that higher fat intakes

Adopting nutrient-

based standards, and

providing the necessary

tools and support for

those who provide

food for under-5s in the

UK, sends a clear

message that policy

makers take the

promotion of good

nutrition seriously.

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are associated with higher totalcholesterol levels among boyseven at this young age and thisagain may suggest that moderatefat intakes among under-5s maybe beneficial for future health.The Caroline Walker Trusttherefore recommends that about35% of food energy in the dietsof under-5s should typically comefrom fat – about the sameproportion as for the populationas a whole. No specificrecommendations are made aboutsaturated fat for under-5s,however, since recommendationsmade for adults are inappropriatefor the under-5s who still have arelatively high milk consumption.

While it is important that childrenwho have poor appetites or whoare fussy eaters get enough foodthat they will accept to ensuretheir healthy growth anddevelopment, evidence alsosuggests that the best sources ofenergy for under-5s are – as theyare for adults – starchycarbohydrate foods. However,under-5s should not be givenlow-fat foods designed for adults(with the exception of semi-skimmed milk – see page 47).Nor should they have diets thatare very bulky and high in fibrewhich may mean they find itdifficult to eat enough calories fortheir needs. For more informationabout fat in the diet, see page 21.

IronThe iron intake of children under5 is lower than currentlyrecommended and there isevidence to suggest that low ironstatus is common in this agegroup (see page 32). For thisreason, the Caroline Walker Trustrecommends that the intakes ofiron in the diet of children in full-day child care should beenhanced to provide not less than80% of the Reference NutrientIntake, and proportionately morefor half-day care as described inthe tables on pages 65-68. Iron

will be provided in particular bymain meals. Drinks (includingmilk) and many snacks are likelyto be low in iron, so it isimportant that children receivethe bulk of their iron from theirmeals. Good sources of iron areshown in Appendix 2 and moreinformation about iron in the dietand improving iron status is givenon page 32.

Care needs to be taken whenplanning menus for childrenreceiving a vegetarian diet toensure they obtain sufficient iron.For more information aboutvegetarian diets, see page 51.

ZincLow intakes of zinc have beenreported among a largeproportion of under-5s –particularly when milk intakesstart to decline – and it isimportant that good sources ofzinc such as meat and meatdishes, cereals, milk and milkproducts and eggs are included inthe diet regularly (see page 34).Since the majority of zinc is likelyto come from foods served atmeals, the Caroline Walker Trustrecommends that the intakes ofzinc for children in full-day childcare be enhanced to provide notless than 80% of the ReferenceNutrient Intake, as for iron above.Good sources of zinc are shownin Appendix 2.

SaltNew guidance on target averagesalt intakes for children havebeen set by the ScientificAdvisory Committee on Nutrition(SACN)3 (see page 35). It issuggested that children aged 1-3years should have no more than2g of salt per day and children 4-5 years no more than 3g of saltper day. The maximumrecommended amount of salt forgroups of 1-4 year olds, 1-2 yearolds and 3-4 year olds used inthis report are given in Appendix

3. These figures have beenincluded in the nutrient-basedstandards but it will be difficult toachieve them. Currently manycommonly consumed foods suchas bread, biscuits, breakfastcereals, cheese, meat and fishproducts and tinned foods arehigh in salt and we do not wantto exclude some of these foodsas they may offer other usefulnutrients. It is possible to achievethe salt recommendations ifpredominantly home-cookedfoods are used, but someflexibility is needed whenplanning menus, to ensure thatcaterers are still able to serve agood variety of foods thatchildren like. Manufacturers andretailers are making changes tothe salt content of manycommonly consumed foods andtherefore over time it maybecome easier to meet the saltrecommendations.

Vitamin DThere is a UK reference value forvitamin D for children aged 6months to 3 years of 7micrograms a day. For childrenaged 4 years and above there isan assumption that they willmake enough vitamin D throughthe action of sunlight on theirskin. As explained on page 28,there is increasing concern thatmany pre-school children havelow vitamin D status and parentsare recommended to continuegiving vitamin D supplementation(through vitamin drops) untiltheir child’s fifth birthday. It isdifficult for children to obtain therecommended amount of vitaminD from food alone since there arefew good food sources of vitaminD (see Appendix 2). Vitamin D isnot included in the nutrient-basedstandards on pages 65-68 butthere is additional information onpage 71 on how to ensure thatmenus are rich in vitamin D.

64


Standards for different periodsof time spent in child care

Children in full-day child care (8 hours or more)Children in child care for a fullday will receive the majority oftheir food while in child care andtherefore it is recommended thatthe food provided gives thechildren 70% of their dailyrequirement for energy and mostother nutrients, and no more than70% of the maximumrecommended amount of non-milk extrinsic sugars andsodium/salt. The remaining 30%of energy and other nutrients willcome from breakfast and fromany drinks, snacks or light mealsthe child receives at home.Children in child care for a wholeday should receive not less than80% of their requirements for ironand zinc, since the diets of somechildren under the age of 5 arelow in these nutrients.

All children are encouraged tohave breakfast. This could eitherbe at home or in child care.Fortified breakfast cereals inparticular provide a valuablesource of some importantvitamins and minerals. Parentsand guardians and thoseproviding child care should worktogether to ensure that childrenhave breakfast either at home orin child care. Therecommendations for dailyintakes of nutrients do notinclude the contribution made bybreakfast.

Children in half-day care Half-day care involves either amorning or afternoon session andis likely to include one meal andat least one snack. Lunch is likelyto be the major provider of foodduring the day and thereforechildren who have lunch and asnack should receive 40% of theirdaily requirement for energy andat least 40% of their daily needsfor most nutrients (and no morethan 40% of the recommendedmaximum amount of non-milkextrinsic sugars or sodium/salt)from these meals, and not lessthan 45% for iron and zinc. Thosehaving a snack and tea shouldreceive not less than 30% of theirneeds (and not less than 35% foriron and zinc).

Children having a snack onlyChildren in child care for amorning or afternoon sessionwhich does not include a mealshould receive a snack duringthis session if the period of careexceeds 2 hours. They shouldhave two snacks if the session is5 hours or more but does notinclude a meal – for example12.30pm to 5.30pm care, missinglunch and leaving before tea.

Aidan and me at the table eatingcucumber and tomatoesEva, aged 4

65


Nutrient

Energy% of the Estimated AverageRequirement (EAR)

Fat% of food energy

Total carbohydrate% of food energy

Non-milk extrinsicsugars% of food energy

Protein% of the ReferenceNutrient Intake (RNI)

Iron% of the RNI

Zinc% of the RNI

Calcium% of the RNI

Vitamin A % of the RNI

Vitamin C % of the RNI

Sodium% of the SACNtarget average

Salt% of the SACNtarget average

Fruit andvegetables

FULL-DAYCARE

70%

About 35%

About 50%

11%

70%

80%

80%

70%

70%

70%

70%

70%

Aim tooffer 4-5differenttypes.

Full-day care includes a morning snack, lunch, afternoon snack and tea. It does not include breakfast.

% of food energy = Percentage of calories consumedEAR = Estimated Average RequirementRNI = Reference Nutrient IntakeSACN = Scientific Advisory Committee on Nutrition3

For an explanation of these terms see page 81.

Morningsession: SNACKand LUNCH

40%

About 35%

About 50%

11%

40%

45%

45%

40%

40%

40%

40%

40%

Afternoonsession: SNACK and TEA

30%

About 35%

About 50%

11%

30%

35%

35%

30%

30%

30%

30%

30%

SNACK only

10%

About 35%

About 50%

11%

10%

10%

10%

10%

10%

10%

10%

10%

LUNCH only

30%

About 35%

About 50%

11%

30%

35%

35%

30%

30%

30%

30%

30%

TEA only

20%

About 35%

About 50%

11%

20%

25%

25%

20%

20%

20%

20%

20%

During the day carers should offer children 4-5 different types of fruits andvegetables at meals and snacks.

Nutrient-based standards for food prepared for 1-4 YEAR OLDSin child care: SUMMARY OF RECOMMENDATIONS

MAX

MIN

MIN

MIN

MIN

MIN

MIN

MAX

MAX

The table below summarises the proportion of nutrients that each eating occasion shouldachieve for children in child care. The figures are for the recommended average nutrientcontent of meals and snacks provided for children over a one-week period.

*

*

66


Nutrient

Energy

Fat

Total carbohydrate

Non-milk extrinsicsugars

Protein

Iron

Zinc

Calcium

Vitamin A

Vitamin C

Sodium

Salt

Fruit andvegetables

FULL-DAYCARE

903

35.0

120.4

26.6

11.0

5.5

4.3

260

300

21

630

1.6

Aim to offer4-5 differenttypes.

Numbers have been rounded up or down where necessary, to ensure that figures for different periodsof child care add up appropriately.

* Full-day care includes a morning snack, lunch, afternoon snack and tea. It does not include breakfast.


516

20.0

68.8

15.2

6.3

3.1

2.4

150

170

12

360

0.9


387

15.0

51.6

11.4

4.7

2.4

1.9

110

130

9

270

0.7

SNACKonly

129

5.0

17.2

3.8

1.6

0.7

0.5

40

40

3

90

0.2

LUNCH only

387

15.0

51.6

11.4

4.7

2.4

1.9

110

130

9

270

0.7

TEA only

258

10.0

34.4

7.6

3.1

1.7

1.4

70

90

6

180

0.5

During the day carers should offer children 4-5 different types offruits and vegetables at meals and snacks.

Nutrient-based standards for food prepared for 1-4 YEAR OLDS in child care

MAX

MIN

MIN

MIN

MIN

MIN

MIN

MAX

MAX

kcals

g

g

g

g

mg

mg

mg

µg

mg

mg

g

This table provides figures for the recommended nutrient content of an average day’s foodand drink over a period of one week or more.

Drinking water should be available throughout the day.

How do the standards translateinto specific nutrients for groupsof children of different ages?

The tables below and on pages 67-68 show whatthe nutrient-based standards mean in terms ofnutrients and foods for groups of children ofdifferent ages.

*

67


Nutrient

Energy

Fat

Total carbohydrate


Protein

Iron

Zinc

Calcium

Vitamin A

Vitamin C

Sodium

Salt

Fruit andvegetables

FULL-DAYCARE

770

30.0

102.7

22.6

10.2

5.5

4.0

245

280

21

560

1.4





440

17.1

58.7

12.9

5.9

3.1

2.3

140

160

12

320

0.8


330

12.8

44.0

9.7

4.4

2.4

1.8

105

120

9

240

0.6

SNACKonly

110

4.3

14.7

3.2

1.5

0.7

0.5

35

40

3

80

0.2

LUNCH only

330

12.8

44.0

9.7

4.4

2.4

1.8

105

120

9

240

0.6

TEA only

220

8.5

29.3

6.5

2.9

1.7

1.3

70

80

6

160

0.4



MAX

MIN

MIN

MIN

MIN

MIN

MIN

MAX

MAX

kcals

g

g

g

g

mg

mg

mg

µg

mg

mg

g



*

68


Nutrient

Energy

Fat

Total carbohydrate


Protein

Iron

Zinc

Calcium

Vitamin A

Vitamin C

Sodium

Salt

Fruit andvegetables

FULL-DAYCARE

1,036

40.3

138.1

30.3

11.9

5.3

4.6

280

315

21

700

1.75




Morning session: SNACKand LUNCH

592

23.0

78.9

17.3

6.8

3.0

2.6

160

180

12

400

1.0


444

17.3

59.2

13.0

5.1

2.3

2.0

120

135

9

300

0.75

SNACKonly

148

5.7

19.7

4.3

1.7

0.7

0.6

40

45

3

100

0.25

LUNCH only

444

17.3

59.2

13.0

5.1

2.3

2.0

120

135

9

300

0.75

TEA only

296

11.6

39.5

8.7

3.4

1.6

1.4

80

90

6

200

0.5



MAX

MIN

MIN

MIN

MIN

MIN

MIN

MAX

MAX

kcals

g

g

g

g

mg

mg

mg

µg

mg

mg

g



*

69


Food group

STARCHYFOODSBread, othercereals andpotatoes

FRUIT ANDVEGETABLES

Good choices

All types of bread – wholemeal,granary, brown, wheatgerm, white,multigrain, soda bread, potato bread,chapatis, naan bread, rotis, rolls, bagels,pitta bread, wraps, tortilla

Potatoes or sweet potatoes – boiled,mashed, baked or wedges

Yam, plaintain, cocoyam, cassava andother starchy root vegetables

Pasta and noodles – wholemeal andwhite

Rice – brown and white rice

Other grains such as couscous orbulgur wheat, maize (polenta) andcornmeal

Breakfast cereals – low-sugar, low-saltcereals such as porridge, puffed wheat,wheat bisks, crisped rice or flakedwheat. Fortified cereals can be a goodsource of iron.

All types of fresh, frozen and cannedvegetables – for example, broccoli,Brussels sprouts, cabbage, carrots,cauliflower, mushrooms, parsnips, peas,peppers, spinach, swede, sweet potato,turnip

All types of salad vegetables – forexample, lettuce, watercress,cucumber, tomato, raw carrot, rawpepper, radish or beetroot

All types of fresh fruit – such as apples,bananas, pears, grapes, kiwi fruit,oranges, plums, berries, melon ormango

All types of canned fruit in juice – forexample, peaches, pears, pineapple,mandarin oranges, prunes, guava orlychees

Stewed fruit such as stewed apple,stewed dried fruit, stewed plums,stewed currants or stewed rhubarb

Dried fruit such as raisins, driedapricots, dates, dried figs, prunes

How much to serve?

Foods from thisgroup should beoffered at everymeal, and can beuseful foods to offeras part of snacks.

These foods shouldmake up about athird of the foodserved each day.

Offer different fruitsand vegetables atmeals and snacks.

Aim for each day’smenu for childcaresettings to offer:1-2 types of fruitand 2-3 types ofvegetables.

Children in full-daycare should have theopportunity to try 4-5 different fruits andvegetables each day.

Notes

Look for lower-salt breads.

Processed potato products likewaffles or smiley faces should beavoided.

Avoid dried or canned ready-prepared pasta in sauce as these arevery salty.

Avoid fried rice or flavoured dried ricein packets.

Avoid sugary breakfast cereals. (If afood contains more than 10g ofsugar per 100g, it is considered ahigh-sugar food.)

Avoid vegetables canned with addedsalt and sugar. Do not overcook fresh vegetables, orcut them up a long time beforecooking and leave them in water, orcook them early and re-heat beforeserving – these practices all reducethe vitamin content.

Sugar can be added to sweeten verysour fruit.

Avoid dried fruit with added sugarand vegetable oil. Serve dried fruitwith meals and not as snacks.

Recommendations for menu planners

In order to help those planning menus to provide a goodvariety of foods in the proportions that are likely to ensurethat all the nutrient needs are met, some simple food-basedrecommendations for 1-4 year olds in childcare settings areincluded here.

70


Food group

MILK ANDMILKPRODUCTSMilk, cheeseand yoghurt

MEAT, FISHandALTERNATIVES

Good choices

Milk – Whole milk should be served forunder-2s. Over-2s can have semi-skimmed milk if they are good eaters.

Cheese

Yoghurt and fromage frais

Meat – all types including beef, lamb,pork, chicken and turkey

Fish includes:• white fish such as cod, haddock,

coley and white fish varieties fromsustainable fish stocks such aspollack, saithe and blue whiting

• oil-rich fish such as herring andmackerel, salmon, trout, sardines,sprats or pilchards. Canned tunadoes not count as an oil-rich fish butis a good source of nutrients.

Eggs – including boiled, scrambled orpoached, or in an omelette

Pulses – including all sorts of beansand peas such as butter beans, kidneybeans, chick peas, lentils, processedpeas or baked beans

Meat alternatives – such as soyamince, textured vegetable protein,quorn or tofu

How much to serve?

Foods from thisgroup should beoffered at 2-3 mealsand snacks each day.

Main meals shouldalways contain anitem from thisgroup.

Foods in this groupare high in iron andcan also be usefullyserved as part ofsnacks – for examplein sandwich fillings.

Notes

Avoid unpasteurised milk and milkdrinks with added sugar.

Avoid unpasteurised cheese andmould-ripened (blue-vein) cheeses. Vegetarian cheese should be usedwhere appropriate.

Avoid yoghurts and fromage fraisthat have a high sugar content (oftenthose with added bits or moussestyle). If the sugar content on ayoghurt or fromage frais label says ithas more than 15g of sugar per100g, it is a high sugar option. It ispreferable to add fresh fruit tonatural yoghurt or fromage frais.

Avoid processed meat productswhich are high in fat and salt, such ascrumb-coated chicken products,burgers, pies and canned meats.Some meat products such assausages are popular with under-5s.Choose good quality versions if youserve these foods, and serve them nomore than once a week.

If you are buying fish from asupermarket, look for the blue andwhite logo of the Marine StewardshipCouncil, which guaranteessustainability.

Serve processed fish products such asfish fingers or fish bites no more thanonce a week.

Make sure fish dishes are free ofbones.

All eggs should be well cooked.

Look for canned pulses with noadded salt and sugar. Dahl and other dishes made frompulses should be made withoutadding a lot of oil and salt. Choose lower-salt and low-sugarbaked beans.

Processed products made from meatalternatives (eg. vegetarian sausages,burgers and pies) can be high in fator salt and should not be servedmore than once in a week.

71


To increase the amount of dietary VITAMIN D in menus served in child care

• Use margarine fortified with vitamin D for baking and as a fat spread.

• Include an oil-rich fish that is rich in vitamin D in the menu at least once a week – for example, herring,mackerel, pilchards, salmon, sardines, trout or roe. These fish contain between 5-14 micrograms of vitamin Dper 100g.

• Canned tuna fish can also make a significant contribution to vitamin D intake as it contains about 3.6micrograms of vitamin D per 100g.

• Egg yolks are rich in vitamin D and eggs contain about 2.0 micrograms of vitamin D per 100g.

• Meat and poultry contribute small but significant amounts of vitamin D.

General menu planning tips

Planning menus ahead will ensure that the best food choices are made and that meals are varied. When choosingmeals to include in menus, remember that:

• A variety of foods should be served throughout the menu cycle and a minimum cycle of three weeks is suggested.

• Choose combinations of colours to make the food attractive. Three or four defined areas of colour look good on aplate.

• A combination of different textures increases appeal. Children will appreciate crisp, crunchy, chewy, smooth andsoft foods.

• Taste should be varied but meals containing too many different or new flavours may not be acceptable tochildren.

• Some finger foods as well as foods which require cutlery allow variation at mealtimes.

Sustainability Concerns about the environmental impact of food travelling long distances,intensive farming and dwindling stocks of some types of fish have promptedGovernment and many local authorities to encourage more sustainableprocurement policies for the buying of food. Those responsible for buyingfood should attempt to buy food that is grown locally and that is in season.They should also consider purchasing fish with the Marine StewardshipCouncil logo which ensures it is from a sustainable source. Carers canencourage children to find out more about the food they eat and to makelinks between food, seasons, agriculture and the environment. Forinformation about sustainable food and educational resources related to foodand the environment, see www.soilassociation.org/foodforlife

72


Sample menus

Below and on pages 73-74 thereare three sample menus whichmeet the nutrient-based standardsfor a group of children aged 1-4years in child care for a full day.Younger children will eat smallerportions and older children willrequire, and want, larger portionsat meals and snacks, as willchildren who do not drink milk.

• Menu 1 is a sample menu for aone-week period. The foodsand drinks in this menuprovide the recommendedamounts of energy andnutrients for children in childcare for a full day. Children inhalf-day care having lunch anda snack would get therecommended amounts byhaving the mid-morning snacksand lunches shown on the

menu. Children in half-day carehaving a snack and a tea wouldget the recommended amountsby having the mid-afternoonsnacks and teas shown on themenu. Children having thesnacks only would achieve therecommendations for snacks.

• Menu 2 is a sample one-weekmenu which would be suitablefor vegetarian children.

• Menu 3 is a sample one-weekmenu which includes a varietyof multicultural dishes.

For more information on thesemenus – including the portionsizes or weights of the items onthe menu, and the recipes for thedishes shown – and additionalinformation on menu planning,see the Eating Well for Under-5sin Child Care: Training Materials(details on page 85).

Mid-morningsnackeg. at 10.00am

Luncheg. at 12.00-1.00pm

Water anddiluted fruit juiceavailable

Mid-afternoonsnackeg. at 3.00pm

Tea eg. at 5.00pm


Monday

MilkCanned peaches injuiceWhole milk yoghurt

Chicken korma Brown rice Naan bread

Fresh fruit salad

MilkCucumber andcarrot sticks Pitta breadMint and cucumberdip

Egg and cresssandwichesLettuce Cherry tomatoes

Banana custard

Tuesday

MilkTabboulehBreadsticks Cherry tomatoes

Lamb burgers Bubble and squeak

Rice pudding withsultanas

MilkPopcorn Sliced pear

Tuna and sweetcornpastaCucumber Red pepper

Fromage frais Satsuma

Wednesday

MilkVanilla yoghurt withbanana

Sardines on toastSliced tomato

Milk jelly withmandarins

MilkWholemeal toastfingers withmargarine Apple

Savoury omelette Baby jacketpotatoes

Semolina with pears

Thursday

MilkFinger foodselection of:sliced grapes, celeryand red pepper

Vegetable lasagne Mixed salad

Stewed apples withcustard

MilkPaprika potatowedgesCheese chunks Orange

Baked beans andwhite toast squares

Yoghurt withdates

Friday

MilkWholemealsavoury pancakeswith butter Apple chunks

Cottage pie Peas Broccoli

Rhubarb crumble

MilkFromage frais with pineapple

Chicken andvegetablecouscousSalad

Fresh fruit jelly

Menu 1: An example menu for 1-4 year olds in child care


73







Tea eg. at 5.00pm


Monday

MilkBreadsticks Houmous dip Cherry tomatoes

Vegetarianbolognese withwholemealspaghetti

Semolina puddingwith dates

MilkCucumber and carrot sticks Cream crackers withsoft cheese

Egg and cresssandwichesLettuce

Fruit flan

Tuesday

MilkWholemeal savourypancakes withbutter Celery sticks

Stuffed peppersPotato salad Beansproutand cherry tomatosalad

Banana custard

MilkFromage frais withcanned peach

Wholemeal pastatwirls Chickpea salad Cucumber andcarrot sticks

Greek yoghurt withorange

Wednesday

MilkApple chunks andsliced grapes

Broccoli quiche Mashed potato Baked beans

Stewed fruit with Greek yoghurt

MilkBreadsticks withmint and cucumberdip Kiwi

Vegetable couscous Mixed salad Homemadecoleslaw

Rice pudding withsultanas

Thursday

MilkYoghurt with slicedbanana

Chickpea fritters Sweet potato Sweetcorn Green beans

Milk jelly withmandarin oranges

MilkPopcorn Apple chunks

Baby jacketpotatoes withratatouille sauce

Oaty fruit crumblewith custard

Friday

MilkWholemeal toastfingers with softcheese Carrot sticks

Mixed beancasserole New potatoesPetits pois Swede

Fresh fruit salad

MilkMini bowl ofcurried rice salad Sliced yellow andorange pepper

Quorn burger in abunLettuce andtomato

Orange andlemon rice

Menu 2: An example vegetarian menu for 1-4 year olds in child care

Cost factors

Healthy eating need not beexpensive. The amount of moneyavailable will have someinfluence on food choice but costconsiderations should not beallowed to override theimportance of providing a healthyand varied diet. Some examplesof ways to ‘buy wisely’ are givenbelow.

• Offer pasta, rice and bread. Allbread is a good source ofnutrients. Some white breadsand soft grain breads haveextra nutrients added.Information is given on thelabel.

• Use vegetables and fruitseasonally.

• If fresh fruit and vegetables areexpensive or not available atcertain times of the year, usetinned or frozen ones (butcheck that tinned vegetableshave no added salt or sugar).

• Lean meat is often better valuethan cheaper, fattier varieties.

• Pulses, eggs and tinned fish areeconomical.

Spending money on cakes,biscuits, squashes and other softdrinks gives poor nutritionalvalue. These foods provideenergy but few nutrients and mayfill children up between mealswith the result that they may noteat enough at mealtimes.

74






Tea eg. at 5.00pm


Monday

MilkWholemeal toastwith soft cheeseGrape slices

Coconut fish curry Basmati riceTomato salad

Stewed fruit Whole milk yoghurt

MilkCucumber andcarrot sticks Pitta bread fingers Houmous dip

Spicy ratatouillewith tofuFlat bread

Watermelon

Tuesday

MilkNatural yoghurtwith banana slices

Chicken fajitas Sweetcorn salsa Mixed salad

Lemon sorbet withwafers

MilkCelery, grapes andred pepper platter

Savoury omelettePotato diceCucumber, redpepper and spring onion

Fruit smoothies Chewy cereal bar

Wednesday

MilkWholemeal savourypancakes with butter Canned peaches

Sweet and sourpork Egg noodles Stir-fried vegetables

Chinese fruit salad

MilkPopcornLychees

Fruity couscous Mixed salad

Fromage frais withdates

Thursday

MilkMini white breadfingers with tunapâtéApple chunks

Channa alooMasoor dahl Mixed vegetablepilau

Neapolitan icecream

MilkRaitaBreadsticks Clementine

Chapati Chickpea salad Cucumber andcarrot stick garnish

Spiced bananacrumble

Friday

MilkFromage frais Pineapple chunks

Chilli con carneJacket potato withcrème fraîche Sliced tomato andwatercress salad

Banana custard

MilkPaprika potatowedges Tomato andsweetcorn salsa

Chicken tikka Tortilla strips orwrapMixed salad

Rice pudding withmandarins

Menu 3: An example menu for 1-4 year olds including some multicultural choices

References1 Department of Health. 1991. Dietary

Reference Values for Food Energy andNutrients for the United Kingdom. Report onHealth and Social Subjects No. 41. London:HMSO.

2 Rogers J, Emmett P and the ALSPAC StudyTeam. 2002. Fat content of the diet amongpre-school children in Britain: relationshipwith food and nutrient intakes. EuropeanJournal of Clinical Nutrition; 56: 252-263.

3 Scientific Advisory Committee on Nutrition.2003. Salt and Health. London: TSO.

Further details of the foods, recipes and portionsizes used in these menus can be found in EatingWell for Under-5s in Child Care: Training Materials(see below).


For more information and advice on menu planning • Additional information on foods and recipes for this age group can be

found in the Caroline Walker Trust’s Eating Well for Under-5s in ChildCare: Training Materials. These training materials also contain a CD-ROMproviding lots of useful information about foods, recipes and menuplanning. This can be obtained from www.cwt.org.uk.

• General information about good choices to make (for example, forsnacks or breakfast) is included in chapter 5. Appendix 2 gives a list ofgood sources of nutrients.

• For other useful sources of information about eating well for the earlyyears, see Appendix 5.

76

Appendix 1

National Standards for Childcare

The National Standards for Childcare represent abaseline of quality which no provider in Englandmay fall below. There are national standards for fivetypes of child care:

• full-day care

• sessional care

• crèches

• out-of-school care

• childminders.

The full standards can be obtained fromwww.ofsted.gov.uk or from DfES publications, POBox 5050, Sherwood Park, Annesley, NottinghamNG15 0DJ. T: 0845 602 2260 (ref: DfES 0486/2001).National Care Standards for Scotland, published in2002, can be found atwww.scotland.gov.uk/library5/education/ncsee.pdf.National Care Standards for Wales, published in2000, can be found at www.csiw.wales.gov.uk

A number of standards are relevant to nutritionalhealth (including Standard 7: Health), but onlystandard 8 is summarised on the right, taken fromstandards for full-day care. (The equivalentstandards for standard 8 for the other childcareoptions are similar to those shown in thisAppendix.)

Standard 8 Food and drink

Children are provided with regular drinks and foodin adequate quantities for their needs. Food anddrink is properly prepared, nutritious and complieswith dietary and religious requirements.

The focus for standard 8

Adequate and nutritious food and drink areessential for children’s well being. The registeredperson and staff have a good understanding ofchildren’s dietary and religious requirements andmeet these appropriately to promote children’sgrowth and development.

Points to consider to meet Standard 8

8.1 Drinking waterFresh drinking water can be made freely availableto children in a variety of ways, such as coveredjugs, water fountains, cooled water units or bottledwater.

Children need regular drinks. You should be alertand responsive to this by:

• making children aware that drinking water isavailable to them at all times

• assisting children to help themselves whereappropriate

• providing suitable bottles, mugs and cups for theages of the children

• encouraging children to ask for a drink

• offering children drinks regularly

• monitoring individual children’s drinking.

Other factors affect how much children need todrink, such as the temperature indoors and outside,energetic play activities, illness and some types ofmedication.

77

Appendix 1 National Standards for Childcare

8.2 MealsWhen offering meals, drinks and snacks to childrenthink about your arrangements for:

• providing healthy and nutritious meals and snacksfor all children

• accommodating special dietary needs andpreferences

• involving children and parents in planning menus

• organising meal times. For example, staff sittingwith children, grouping of children (ages, familygroups) and encouraging independence such aschoices, self-service

• meeting the needs of children who arrive early inthe morning or leave late in the afternoon

• providing suitable utensils, plates, cups andbottles.

8.3 Information from parentsWhen complying with parents’ wishes about foodand drink consider:

• children’s feelings. For example, they may feeluncomfortable about their particular needs.

• obtaining information and advice regardingspecial diets and food allergies

• ways of ensuring staff are fully informed.

8.4 Food and drink provided by parentsIt is helpful to discuss with parents who providefood and drink for their children the importance of:

• providing safe foods, taking into account thestorage facilities available

• suitable implements and containers, such as coolboxes.

You also need to consider your arrangements ifparents forget to bring lunch, do not provideenough food or children do not eat what isprovided.

You may find it helpful to inform parents ofprocedures and policies regarding food and drink,such as checking lunchboxes for ‘unsafe’ items,bearing in mind that food swapping may occuramong children, some of whom may have allergies.

What the Inspector looks for:

• Children’s records indicating their dietary needs

• Your arrangements for providing food and drink

• How you find out about and meet children’sdietary needs

• The arrangements you make when parentsprovide food and drink for their child.

The Inspector bases judgements on the extent towhich:

• children have access to fresh drinking water

• drinks are provided regularly, especially wherechildren are unable to ask for one

• children know they can have a drink if they wantone

• staff are aware when children need to drink, forexample, after physical play

• all relevant staff are aware of children withspecial dietary needs, and these needs aresensitively cared for

• if snacks and meals are provided, these arehealthy and nutritious.

78

Appendix 2

Good sources of vitamins and minerals

EXCELLENT

liver*liver sausage/pâté*carrotsspinachsweet potatoesred peppersmangocanteloupe melondried apricots

fortified breakfast cerealsherringspilchardssardinestunacanned salmonegg

liver and liver pâté*pork, bacon and hamfortified breakfast cerealsmalted drinks

liver*kidney

fortified breakfast cerealscanned salmon, tunapilchardschicken

GOOD

nectarinepeachblackcurrantsfresh or canned apricotswatercresstomatoescabbage (dark)broccoliBrussels sproutsrunner beansbroad beansmargarinebuttercheese kidney

liver* (other than chickenliver)liver sausage/pâté*margarine

wholemeal breadyeast extractoatcakescurrant bunsnutspotatoes

milkmalted drinksfortified breakfast cerealsalmonds

lean meatsausageskidneysherringssardines

USEFUL

canned salmonherringsegghoneydew melonprunesorangesweetcornpeaswhole milk

chicken liver*malted-style drinks

lean meatchicken and other poultryeggswhite or brown breadsemi-sweet biscuits

lean meat or poultrybaconmackerel, tuna, salmonsardines, pilchardscheese yoghurteggs

wholemeal breadpeanut butteryeast extractbaconliver sausage*

VITAMIN A

VITAMIN D

THIAMIN

RIBOFLAVIN

NIACIN

This Appendix shows a number of foods and drinkswhich are important sources of certain vitamins andminerals. These are based on average servings.

79

Appendix 2 Good sources of vitamins and minerals

EXCELLENT

whole grain cerealsred meatpoultryliver*oily fish

liver*kidneyoily fish

most fortified breakfastcereals, eg. cornflakes,bran flakes, crisped riceliver*spinach

blackcurrantsorange (and orange juice) strawberriescanned guavaspring greensgreen and red peppers(raw)

fortified breakfast cerealsliver*kidneyliver sausage/pâté*

green leafy vegetablessardinescheesetofu

GOOD

potatoesbananasnutsdried fruitwhite fish

beeflambporkturkeywhite fisheggs

yeast extractcabbageBrussels sproutsbroccolipeasorangemelonkidney

broccolicabbagecauliflowerspinachtomatoBrussels sproutswatercresskiwi fruitmangograpefruit

wholemeal bread/flourwheat bisksbeefbeefburgercorned beeflambsardines, pilchardssoya beanschick peaslentilsspinachbroccolispring greensdried apricotsraisins

pilchardsyoghurtmilk (all types)soya drink fortified withcalciumcheese spreadsesame seedssesame pasteground almonds

USEFUL

baked beanslentils and other pulsesgreen vegetablestomatoeswholemeal breadcheese

chickenmilkcheeseyoghurtmarmiteribenabran flakes

wholemeal bread/flourwheat biskscauliflowerbeefrunner beanstomatoesparsnippotatoesgreen leafy saladsackeepeanuts

potatoesgreen beanspeassatsumaseating applesnectarinespeachesraspberriesblackberries

white breadbaked beansbroad beansblack-eyed peasblackcurrantssalmontunaherringssausagechicken and other poultryeggtofu

canned salmonmuesliwhite bread/flourpeas, beans, lentilsdried fruitorangeegg yolk

VITAMIN B6

VITAMIN B12

FOLATE

VITAMIN C

IRON

CALCIUM

* Liver, including liver pâté, is very rich in vitamin A which can be harmful in large amounts (see page 27.)It is recommended that these foods are given to children no more than once a week.1

80

Appendix 2 Good sources of vitamins and minerals

EXCELLENT

liver*kidneylean meatcorned beef

whole grain orwholewheat breakfastcereals such as bran flakes,wheat bisks, shreddies,shredded wheat, sultanabran wholemeal breadsbaked beans, chick peas,kidney beans (and mostbeans)lentilsdried apricots, figs, prunes

GOOD

baconhampoultrycanned sardinesshrimps and prawnstofuwhole grain breakfastcereals, eg. puffed wheat,bran flakes, wheat bisksnuts

muesliwholemeal pastabrown breadswhite bread with addedfibrebaked potato with skinsweet potatobroad beansfresh or frozen peassweetcornbroccoliBrussels sproutsquornblackberriesdried datesalmondshazelnuts

USEFUL

sausagescold cooked meatscanned tuna or pilchardseggsmilkcheesebeans and lentilsbrown or wholemeal breadplain popcornsesame seeds

puffed wheat cerealbrown ricewhite pitta breadpizzapotatoesyamhoumouscanned peascabbagecarrotsplantainbananamangoraisinssunflower seedspotato crisps

ZINC

FIBRE(non-starchpolysaccharides –NSP)

* Liver, including liver pâté, is very rich in vitamin A which can be harmful in large amounts (see page 27.)It is recommended that these foods are given to children no more than once a week.1

Reference

1 Scientific Advisory Committee on Nutrition. 2005. Review ofDietary Advice on Vitamin A. London: TSO.

81

Appendix 3

Dietary Reference Values for energy and nutrients for under-5s

In 1991 the Department of Health Committee onMedical Aspects of Food and Nutrition Policy(COMA) published Dietary Reference Values whichdefine the amounts of energy and nutrients thatwould meet the daily needs of most people in theUK.1 The Dietary Reference Values include‘Estimated Average Requirements’, and ‘ReferenceNutrient Intakes’. These terms are explained below.

Dietary Reference Values (DRVs)

Dietary Reference Values (DRVs) are benchmark intakesof energy and nutrients. They indicate the amount ofenergy or individual nutrients needed by a group ofpeople of a certain age range (and sometimes gender)for good health. They are not designed for working outa diet for an individual; eating less of a nutrient than isrecommended cannot tell us that an individual isdeficient. However, if more than quite a few people in agroup fall below the recommendations, this suggeststhat some individuals in that population may be at riskof deficiency.

The DRVs for energy are described as the EstimatedAverage Requirement (EAR). Most other nutrients havean EAR and also a Reference Nutrient Intake (RNI) and aLower Reference Nutrient Intake (LRNI). These terms aredescribed below.

Estimated Average Requirement (EAR)

The average amount of energy or nutrients needed bya group of people. Half the population will have needsgreater than this, and half will have needs below thisamount.

Reference Nutrient Intake (RNI)

This is the amount of a nutrient which is enough tomeet the dietary requirements of about 97% of agroup of people. If people get more than this amountthey will almost certainly be getting enough.

Lower Reference Nutrient Intake (LRNI)

This is the amount which is sufficient for the 3% of agroup of people with the smallest needs. Most peoplewill have needs greater than this.

Energy

The Estimated Average Requirements (EAR) forenergy for children aged 6 months to 4 years – thatis how many calories a day they need – are shownbelow.

Estimated Average Requirements for energy forchildren under 5 years

Age of child Estimated Average Requirement in kcal (kJ) per day*

Boys Girls

6 months 760kcal (3,200kJ) 710kcal (2,980kJ)

9 months 880kcal (3,680kJ) 820kcal (3,420kJ)

1 year 960kcal (4,020kJ) 910kcal (3,800kJ)

11/2 years 1,080kcal (4,520kJ) 1,020kcal (4,260kJ)

2 years 1,190kcal (4,960kJ) 1,130kcal (4,720kJ)

21/2 years 1,280kcal (5,370kJ) 1,230kcal (5,140kJ)



* In practice the intakes of energy and of nutrients needs to be averaged over severaldays to take account of variations in appetite and in the diverse foods in a diet from dayto day.

The energy we need every day is determined bothby a basic level of requirement to keep our bodiesfunctioning (called the Basal Metabolic Rate orBMR) and by the amount of physical activity thatwe do (for example moving around, walking, orexercising). People who are inactive have lowerenergy needs and will eat less food to maintaintheir body weight. It becomes much harder to getall the nutrients needed for good health if less foodis eaten.

Fat and carbohydrateThere are no recommendations for the under-5s interms of the proportion of energy in the diet whichshould come from fat and total carbohydrate. Ifunder-5s have too little fat, this may affect theirgrowth and development and their diet may be toolow in other essential nutrients. Between the agesof 2 and 5 years children’s diets should movetowards the recommendations currently made forthe over-5s. However, in this report the CarolineWalker Trust argues that diets which provide about35% of energy from fat are likely to be suitable forchildren aged 1-4 years (see page 21).

The recommendation currently made to restrict theamount of NME sugars in the diet to no more than11% of energy intake is, however, appropriate forthe under-5s.

82

Appendix 3 Dietary Reference Values for energy and nutrients for under-5s

Derived nutrient values used forcalculating the nutrient-basedstandards in this report

The energy and nutrient values that have been usedto create the nutrient-based standards in this reportare based on the current Dietary Reference Valuesfor the UK1 and additional recommendations on saltintakes.2

Energy values are based on the following DietaryReference Values:

• 1-2 year olds: average for boys and girls at 12months, 18 months, 24 months and 30 months

• 3-4 year olds: average for boys and girls aged 3years and 4 years.

Values for other nutrients are based on thefollowing dietary reference values:

• 1-2 year olds: as for 1-3 year olds

• 3-4 year olds: 50% as for 1-3 year olds and 50%as for 4-6 year olds.

The values for children aged 1-4 years are theaverage of those aged 1-2 and 3-4 years.

Nutrient 1-2 year olds 3-4 year olds 1-4 year olds Energy kcals 1,100 1,480 1,290

MJ 4.6 6.2 5.4

Total fat g 42.8 57.6 50.2

Carbohydrate g 146.7 197.3 172.0

Non-milk extrinsic sugars (NME sugars) g 32.3 43.4 37.8

Protein g 14.5 17.1 15.8

Iron mg 6.9 6.5 6.7

Zinc mg 5.0 5.8 5.4

Calcium mg 350 400 375

Vitamin A µg 400 450 425

Vitamin C mg 30 30 30

Sodium mg 800 1,000 900

Salt g 2 2.5 2.3

References

1 Department of Health. 1991. Dietary Reference Values for FoodEnergy and Nutrients for the United Kingdom. Report on Healthand Social Subjects No. 41. London: HMSO.

2 Scientific Advisory Committee on Nutrition. 2003. Salt andHealth. London: TSO.

83

Appendix 4

Food-related customs

This is a guide to some of the differences in foodchoice commonly observed by those from differentreligious and cultural groups. It is important toemphasise that there may be individual differencesin food choices between families, and thoseproviding child care should not make assumptionsabout anyone’s food preferences. It is important tofind out about each child from his or her parent orguardian.

Jewish Hindu1 Sikh1 Muslim Buddhist Rastafarian 2

Eggs No blood spots It varies Yes Yes It varies It varies

Milk/yoghurt Not with meat Yes Yes Yes Yes It varies

Cheese Not with meat Yes Yes It varies Yes It varies

Chicken Kosher It varies It varies Halal No It varies

Mutton/lamb Kosher It varies It varies Halal No It varies

Beef and beef products Kosher No No Halal No It varies

Pork and pork products No Rarely Rarely No No No

Fish With fins and scales With fins and scales It varies It varies It varies Yes

Shellfish No It varies It varies It varies No No

Butter/ghee Kosher Yes Yes Yes No It varies

Lard No No No No No No

Cereal foods Yes Yes Yes Yes Yes Yes

Nuts/pulses Yes Yes Yes Yes Yes Yes

Fruits/vegetables Yes Yes3 Yes Yes Yes Yes

Fasting 4 Yes Yes Yes Yes Yes Yes

1 Strict Hindus and Sikhs will not eat eggs, meat, fish, and some fats.

2 Some Rastafarians are vegan.

3 Jains have restrictions on some vegetable foods. Check with the individuals.

4 Fasting is unlikely to apply to young children.

84

Appendix 5

Useful addresses and further information

Useful addresses4Children (formerly Kids’ Club Network)City Reach5 Greenwich View PlaceLondon E14 9NNT: 020 7512 2112E: [email protected]

Anaphylaxis CampaignPO Box 275FarnboroughHampshire GU14 4SXT: 01252 377140www.anaphylaxis.org.uk

Association of Breastfeeding MothersPO Box 207BridgwaterSomerset TA6 7YTT: 0870 401 7711E: [email protected]

BLISS (The Premature Baby Charity)68 South Lambeth RoadLondon SW8 1RL T: 020 7820 9471 E: [email protected]

Breastfeeding NetworkPO Box 11126Paisley PA2 8YB ScotlandT: 0870 900 8787www.breastfeedingnetwork.org.uk

British Allergy FoundationDeepdene House30 Bellegrove RoadWellingKent DA16 3BYT: 020 8303 8525E: [email protected]

British Dental Association64 Wimpole StreetLondon W1N 8ALT: 020 7935 0875www.bda.org

British Dietetic Association (PaediatricGroup)5th Floor, Charles House148-9 Great Charles StreetQueenswayBirmingham B3 3HT T: 0121 200 8080 E: [email protected]

British Heart Foundation 14 Fitzhardinge StreetLondon W1H 6DHT: 020 7935 0185Heart Information Line: 08450 70 80 70www.bhf.org.uk

British Nutrition FoundationHigh Holborn House52-54 High HolbornLondon WC1V 6RQT: 020 7404 6504 E: [email protected]

Chartered Institute of EnvironmentalHealthChadwick Court15 HatfieldsLondon SE1 8DJT: 020 7928 6006E: [email protected]

Coeliac UKSuites A-D Octagon CourtHigh WycombeBuckinghamshire HP11 2HST: 01494 437278

Community Practitioners’ and HealthVisitors’ Association (CPHVA)33-37 Moreland StreetLondon EC1V 8HAT: 020 7780 4000E: [email protected]

Daycare Trust21 St George’s RoadLondon SE1 6EST: 020 7840 3350E: [email protected]

Diabetes UK Macleod House10 ParkwayLondon NW1 7AAT: 020 7424 1000E: [email protected]

The Food Commission94 White Lion StreetLondon N1 9PFT: 020 7837 2250E: [email protected]

Food Standards Agency www.food.gov.ukSee also page 85 for details of resourcesavailable from the Food Standards Agency.

Health Promotion Agency for NorthernIreland 18 Ormeau AvenueBelfast BT2 8HST: 028 9031 1611E: [email protected]

La Leche LeagueBM 3424London WC1N 3XXT: 020 7242 1278www.lalecheleague.org

Learning Through Landscapes3rd floorSouthside OfficesThe Law CourtsWinchester S023 9DL

The Maternity Alliance (Closed December2005)Maternity Alliance publications can bebought from: National Childbirth TrustT: 0870 112 1120E: [email protected]

Mudiad Ysgolion Meithrin(Welsh early years specialists)Boulevard St BrieucAberystwythCereidigion SY23 1PDT: 01970 639639www.mym.co.uk

National Asthma CampaignProvidence HouseProvidence PlaceLondon N1 0NTT: 020 7226 2260Helpline: 0845 701 0203www.asthma.org.uk

National Childbirth TrustAlexandra HouseOldham TerraceLondon W3 6NHT: 0870 770 3236E: enquiries@national-childbirth-trust.co.ukwww.nctpregnancyandbabycare.com

National Childminding AssociationRoyal Court81 Tweedy RoadBromleyKent BR1 1TGT: 0845 880 0044www.ncma.org.uk

National Children’s Bureau8 Wakley StreetLondon EC1V 7QET: 020 7843 6000www.ncb.org.uk

Early Childhood UnitT: 020 7843 6080www.earlychildhood.org.uk

National Council of Voluntary Child CareOrganisationsUnit 4Pride Court80-82 White Lion StreetLondon N1 9PFT: 020 7833 3319E: [email protected]

85

Appendix 5 Useful addresses and further information

National Day Nurseries AssociationOak HouseWoodvale RoadBrighouseWest Yorkshire HD6 4ABT: 0870 774 4244E: [email protected]

National Heart Forum Tavistock House SouthTavistock SquareLondon WC1H 9LGT: 020 7383 7638www.heartforum.org.uk

National Institute for Health and ClinicalExcellence (NICE) MidCity Place71 High HolbornLondon WC1V 6NAT: 020 7067 5800www.publichealth.nice.org.uk

NHS DirectT: 0845 4647www.nhsdirect.nhs.uk

NHS Health ScotlandWoodburn HouseCanaan LaneEdinburgh EH10 4SGT: 0131 536 5500www.healthscotland.com

Northern Ireland Pre-school PlaygroupAssociation (NIPPA)6c Wildflower WayBelfast BT12 6TAT: 028 9066 2825E: [email protected]

Play Wales/Chwarae CymruBaltic HouseMount Stuart SquareCardiff CF10 5FHT: 029 2048 6050E: [email protected]

Pre-school Learning AllianceThe Fitzpatrick Building188 York WayLondon N7 9ADT: 020 7697 2500www.pre-school.org.uk

Royal College of Paediatrics and ChildHealth50 Hallam StreetLondon W1W 6DET: 020 7307 5600www.rcpch.ac.uk

The Royal Institute of Public Health andHygiene28 Portland PlaceLondon W1B 1DET: 020 7580 2731www.riph.org.uk

Scottish Pre-school Play Association45 Finnieston StreetGlasgow G3 8JUT: 0141 221 4148www.sppa.org.uk

Vegan SocietyDonald Watson House7 Battle RoadSt Leonard’s on SeaEast Sussex TN37 7AAT: 01424 427393www.vegansociety.com

Vegetarian SocietyParkdaleDunham RoadAltrinchamCheshire WA14 4QGT: 0161 928 0793www.vegsoc.org

Wales Pre-school Playgroups AssociationLadywell HouseNewtownPowys SY16 1JBT: 01686 624573www.walesppa.org.

Working Families1-3 Berry StreetLondon EC1V 0AAT: 020 7253 7243E: [email protected]

Further information Caroline Walker TrustpublicationsFor details see www.cwt.org.uk.

Eating Well for Under-5s in Child Care:Training Materials for People Workingwith Under-5s in Child CareTraining materials on eating well andpractical menu planning advice for use byindividual child carers, or by those offeringtraining to owners, managers, cateringstaff, local authority staff, childminders,teachers and other carers in environmentsproviding child care for infants and under-5s. The materials include a CD-ROM withuseful information about foods, recipes andmenu planning.

Eating Well at SchoolNutritional and practical guidelines for foodserved in schools throughout the day tochildren aged 5-18 years.

Eating Well for Looked After Children andYoung PeopleNutritional and practical guidelines for foodserved to 5-18 year olds who are cared forin children’s homes or by foster carers.

Department of HealthpublicationsAvailable from:Department of HealthPO Box 777London SE1 6XHT: 0800 555777

Breast Feeding (2004) Leaflet

Bottle Feeding (2005) Leaflet

Weaning (2005) Leaflet

Practical Food Hygiene. Poster in A3 or A2Sizes

Birth to Five: Your Complete Guide toParenthood and the First Five Years ofYour Child’s Life (2005 edition)

Welfare Food Scheme: Nursery Milk Guidefor Providers of Day Care for ChildrenUnder Five (2003) Leaflet

For information on the new Healthy Startscheme see www.healthystart.nhs.uk

Food Standards Agencypublications Available from:PO Box 369HayesMiddlesex UB3 1UTT: 0845 606 0667F: 020 8867 3225Minicom (for people with hearingdisabilities): 0845 606 0678E: [email protected]

Be Allergy Aware FSA0002

Ten Tips for Food Safety FSA0006

The Food Safety Act 1990 and YouFSA0238. Booklet summarising the FoodSafety Act.

The Balance of Good HealthFSA/0008/0604

Healthy Diets for Infants and YoungChildren FSA0249

Feeding Your Baby FSA/0454/0602

Feeding Your Toddler FSA/0455/0105

Feeding Your Growing ChildFSA/0456/0602

Further information on healthy eating canbe obtained from:www.eatwell.gov.ukwww.salt.gov.ukwww.food.gov.uk

National Children’s Bureaupublication www.ncb-books.org.uk

Child Development from Birth to Eight: APractical FocusA book for all who work with children butneed to know more about how childrenlearn and develop.ISBN 1 904787 282

86


NHS Health Scotland/ScottishExecutive publications www.healthscotland.com/publications

Nutritional Guidance for Early Years: FoodChoices for Children Aged 1-5 Years inEarly Education and Childcare SettingsScottish Executive, 2006Orders: 0131 622 8283E: [email protected] 0755947878

Adventures in Foodland 2005Nutrition resource aimed at carers of pre-school children, especially carers of veryyoung children in the 0-3 age group.1-84485-113-3

Fun First Foods 2005Provides tips, advice, recipes andinformation on the different stages ofweaning.1-84485-274-1

Is your Child a Fussy Eater? Leaflet (2003)

It’s Never Too Early to Think about YourBaby’s Teeth Flyer (1998)

Mothers Caring for Young Children’sTeeth Flyer (1997)

Health Promotion Agency(Northern Ireland) publications www.healthpromotionagency.org.uk/resourcesT: 028 9031 1611F: 028 9031 1711

Off to a Good Start: All You Need toKnow about Breastfeeding Your Baby(2004) Contains essential facts to help mothers inmaking informed choices about how tofeed their babies.1-84485-283-0

Weaning Made Easy: Moving from Milk toFamily Meals (2005)For parents of young babies and healthprofessionals working with this group.

Food 4 Play Pack (2005) Presented in three sections: Eating forHealth, Food Activity Pack, and GoodPractice.

Getting a Good Start – Healthy Eatingfrom One to Five (2004)This booklet outlines advice on many keynutritional issues for children aged 1-5.

Nutrition Matters for the Early Years –Guidance for Feeding Under Fives in theChildcare Setting (2005)

Publications from the WelshAssemblyBilingual resources (in English and Welsh)have been produced by the WelshAssembly Government and can bedownloaded as PDF files from: www.cmo.wales.gov.uk/content/publications/index-e.htm

Weaning booklets:

Help ... My Child is Fussy with Food

Stage 1: Easy to Cook Family Foods forYour Baby



Publications from the BritishDietetic Association PaediatricGroupwww. bda.uk.com

After Milk – What’s Next? (2004)

Help – My Child Won’t Eat! (2004)

Food for the Growing Years (2004)

Food for the School Years (2004)

National Childbirth TrustpublicationsAvailable from: www.nctms.co.uk

NCT Book of BreastfeedingMary Smale (1999)Harper CollinsISBN 0007136080

Breastfeeding – How to Express and StoreYour MilkBooklet (2000)

Successful BreastfeedingRoyal College of Midwives (2001)Churchill LivingstoneISBN 0443059675

Publications from BLISS, thePremature Baby Charitywww.bliss.org.uk (Address on page 84.)

Breastfeeding Your Premature Baby(2005) Leaflet

Weaning Your Premature Baby (2003)Leaflet

EquipmentBoth of the following are available from:www.nctms.co.uk

Doidy cups Doidy cups are specially designed to helpyoung children drink from a cup.

Weaning cubesFor freezing or storing baby food or breastmilk.

Cookery books 365 Recipes for Babies, Toddlers andChildrenBridget Wardley and Judy MoreDuncan BairdISBN 1 84483 036 5

Baby and Child Vegetarian RecipesCarol Timperley Ebury Press, LondonISBN 0091853001

Dump The JunkMary Whiting and Ben Nash Moonscape LtdISBN 0954432401

Finger Food for Babies and ToddlersJennie Malzells VermillionISBN 0091889510

First Foods and WeaningRavinder Lilly Harper Collins ISBN 0007136072

The Nursery Food BookMary Whiting and Tim Lobstein Arnold (Hodder Headline) ISBN 0340718943

Food customsCelebration!Barnabas and Annabel Kindersley Dorling Kindersley Ltd, LondonISBN 0 7513 5650 6

Festivals and CelebrationsJim Fitzsimmons and Rhona WhitefordScholastic Educational Books ISBN 0 590 53083 6

‘SHAP’ calendar of religious festivalsA calendar of festivals for the current year.Available from: SHAP Working Party c/o National Society Religious EducationCentre36 Causton StreetLondon SW1P 4AUT: 020 7932 1194www.shap.org.uk

87


Learning throughplay Clay and DoughLynne BurgessScholastic Educational Books ISBN 0 590 53638 9

FoodLesley ClarkIn the ‘Themes for Early Years’ series.Scholastic Educational Books ISBN 0 590 53719 9

Food and Cooking – Ready, Steady, PlaySandy Green David Fulton (2004)ISBN 184312100X

Fun OutdoorsFun with Role PlayFun with GamesBooklets for parents and carers aimed at 3-5 year olds.The Basic Skills Agencywww.basic-skills.co.uk

The Little Book of DoughLynn Garner, Melanie Roan, Marion Taylorand Sally Featherstone Featherstone EducationISBN 1905019106

Snack TimeJenni Clark Featherstone Education (2005)ISBN 1 905019 19 X

ORGANISATIONS ANDWEBSITESThe Children’s Play Councilwww.ncb.org.uk/cpc

Early Years Outdoorswww.ltl.org.ukDedicated early years service from Learningthrough Landscapes offers resources toencourage outdoor play.

Sources of resourcematerial for food-related activitiesCatalogues are available from the followingcompanies.

ASCO Educational Supplies Ltd19 Lockwood WayParkside LaneLeeds LS11 5THT: 0113 270 7070E: [email protected] www.ascoeducational.co.uk

Early Learning CentreSouth Marston ParkSwindon SN3 4TJT: 0870 535 2352 www.elc.co.uk

The Festival Shop Ltd56 Poplar RoadKings HeathBirmingham B14 7AG T: 0121 444 0444E: [email protected]

Hope EducationHyde BuildingAshton RoadHydeCheshire SK14 4SHT: 0845 120 2224E: [email protected]

Pictorial Charts Educational Trust27 Kirchen RoadLondon W13 OUDT: 020 8567 9206E: [email protected]

Schofield and Sims LtdDogley MillFenay BridgeHuddersfieldWest Yorkshire HD8 0NQT: 01484 607080E: [email protected]

Scholastic UKWestfield RoadSoutham CV33 0JHT: 01926 813910E: [email protected]

Training in ‘EatingWell’ for early yearscare providersIn the UK, registered dietitians (RD) andregistered public health nutritionists(RPHNutr) are the professionals qualified toprovide advice and training on goodnutrition in public settings.

Registered dietitians can be found via theBritish Dietetic Association:www.bda.uk.com

Registered public health nutritionists can befound via the Nutrition Society:www.nutritionsociety.org

The Eating Well for Under 5s: TrainingMaterials which accompany this report (seepage 85) provide the contact details ofindividuals around the UK who are suitablyqualified and who are willing to offertraining to early years settings. For an up-to-date list of trainers, see www.cwt.org.uk

88

Index

Aactivities: food-related 57activity 9, 20, 46 allergies 38, 52atmosphere at eating times 11, 55awards: healthy eating awards 60

BB vitamins 29, 78behaviour and diet 53bottle feeds 39, 43breakfast 11, 54breastfeeding 12, 38

Ccalcium 34, 52, 79calories 20, 81carbohydrates 22, 69, 81 carer involvement in meals 55carotene 27celebrations 58childcare places 15constipation 25copper 35cups for infants 42, 50customs related to food 83

Ddairy-free diets 52dental health 10, 23, 49, 50diarrhoea 25Dietary Reference Values 81disabilities: children with 53drinks: for infants 12, 42

for under-5s 9, 46, 49DRVs 81

EEAR 81energy (calories) 20, 81equal opportunities 12, 46erosion of teeth 50Estimated Average Requirement 81exercise 9, 20, 46

Ffat in the diet 21, 62, 81fatness in children 20, 47festivals 58fibre 25, 80fish 45, 70, 71five a day 31folate 29, 79food groups 45, 69food policy 59food safety: infants 13, 43

under-5s 10, 53fruit 30, 31, 45, 69fruit drinks 42, 49full-day care 64

Ggroups: food groups 45, 69

Hhalf-day care 64

Iinfant formula 39infant nutrition 38intrinsic sugars 22iodine 35iron 32, 41, 63, 79

Jjuice 42, 49

Llearning through food 11, 56listening: to children 57

to parents 11, 57liver 27

Mmagnesium 35mealtimes 54, 55, 56meat 32, 70menus 57, 71, 72milk products 45, 70milk: for babies 12, 38

for under-5s 47, 70minerals 32, 78

Nn-3 polyunsaturated fats 21niacin 29, 78NMES 23non-milk extrinsic sugars 23non-starch polysaccharides 25, 80NSP 25, 80nutrient-based standards 8, 61, 65nutrition policy 59nuts 53

Oobesity 20, 47omega-3 fats 21

Pparents: involving parents 11, 57phosphorus 36physical activity 9, 20, 46policy: nutrition policy 59polyunsaturated fats 21potassium 36prebiotics/probiotics 25protein 24

Rrecommendations 8

for menu planners 69Reference Nutrient Intakes 24, 81refusal of food 56retinol 27rewards 55

riboflavin 29, 78RNI 24, 81

Ssafety of foods: see ‘food safety’salt 34, 63sample menus 72saturated fat 21selenium 36snacks 11, 45, 54, 55, 64social skills 11sodium 34, 63soft drinks 49special diets 52special needs 53standards: nutrient-based 8, 61, 65starchy foods 22, 69sugars 22, 49, 50supplements 21, 53sustainability 11, 71

Ttea (beverage) 32, 49teeth: see dental healththiamin 29, 78timing: of feeds for infants 40

of meals and snacks 11, 54tooth erosion 50toothbrushing 51training 8, 87

Vvariety of foods 44vegan diets 52vegetables 31, 45, 69vegetarian diets 33, 51, 73vitamin A 26, 27, 78vitamin B6 26, 30, 79vitamin B12 26, 30, 79vitamin C 26, 30, 32, 79vitamin D 26, 28, 42, 63, 71, 78vitamin drops 28, 41, 52vitamin E 26vitamin K 26vitamins 26, 78

Wwater 49

for babies 40, 42weaning 13, 40, 42

Zzinc 34, 63, 80

Eating well for under-5s in child care · Eating Well for Under-5s in Child Carewas originally...

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