1. Have a fruit bowl permanently available – full and sporting ripe and fresh fruit.
2. Don’t allow chocolate, sweets, cakes, crisps and other junk foods to become everyday foods. Just get them in for special occasions only.
3. Encourage them to drink water and enjoy it, by serving water with every meal. Put water in a jug with some ice and have nice glasses/beakers to make it more appealing.
4. Make sure every meal comes with at least one sort of veggie or salad accompaniment. Don’t make it unusual for a vegetable to turn up on their plates!
5. Have a think about your cooking and see about ways you could reduce the fat, salt or sugar content of your meals.
6. Help children build on their knowledge of healthy eating by talking about what a balanced meal is. The 5-a-day message is obvious, but discuss other aspects of healthy eating too (for ideas, see my other blog posts).
7. Aim to make healthy alternatives to favourite ‘junk’ food. Have a home-made-takeaway night and make your own version of pizza, burgers or Chinese – with a healthy twist of course.
8. Offer some choice, but within a healthy range. Children like to feel in control without realising you’re influencing what they eat.

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

As a specialist paediatric dietitian, I am committed to ongoing professional development (‘CPD’) and that’s part of the reason why I’m so involved in research – either through editing scientific papers, being part of research projects, or analysing medical research papers for the latest evidence (usually accompanied by a mug of tea!).

An area that I don’t feel receives the attention it deserves is in childhood measurement. Parents are frequently encouraged to have their babies and children weighed and measured…and yet how accurate are these measurements? Are scales and length measures regularly calibrated and serviced? Does the health professional undertaking the measurements receive regular training and can they be certain of their technical error of measurement (we’re all human afterall).

I have recently been involved in a training program to teach professionals some of the basics of measuring children, and I’ve also been involved in a research project investigating measuring children with special needs – here’s a link to my recent publication: https://www.ncbi.nlm.nih.gov/pubmed/?term=hardy+anthropometric+measurements+children+special+needs

As parents, I would encourage you to:

• ask at your clinic to have your infant/child measured in length as well as weight
• question unusual measurements (it’s good practice to take two repeat measurements)
• rely on serial measurements (trends) rather than one-offs
• try to make sure weighing/measuring conditions are the same each time eg clothes/nappy off, same time of the day, after voiding etc.

And lastly, don’t be afraid to ask questions about the measurements you’re given!

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

Food allergy management used to be simple: avoid avoid avoid!!

Research is increasingly telling us that this may not always be the best tactic.

Allergy to cow’s milk involves an immune response to proteins in cow’s milk. But, food processing such as cooking or baking at high temperatures, exposure to low pH and enzymatic digestion may destroy certain proteins (‘conformational epitopes’) in the milk – meaning that many children (some say up to 75%) may actually tolerate small amounts of baked milk containing foods like muffins, cakes, breads and waffles.

Furthermore, there may be some children who respond well to regular exposures to small amounts of heat-treated milk.

So what is a milk ladder?

A milk ladder provides a step-wise approach to gradually challenge a child with cow’s milk containing foods. The principle is to start with a very small amount of extensively heat treated milk within a product (such as a biscuit) and progress as tolerated. If the food in a certain step of the ladder is tolerated, the advice is for the child to continue eating that food, and then try the food in the next step.

Is a milk ladder for everyone?

No! Certain groups of children may react badly to any cow’s milk protein, and a challenge should only be undertaken with support from a doctor or the child’s dietitian. There are different milk ladders available – and no gold-standard (research is still being undertaken), so it’s best to discuss which ladder will be most suitable for you and your child.

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

I’m often asked about when to introduce foods that could potentially cause an allergic reaction. In the past, children have been held off eating peanuts up until their third birthday or possibly longer. However, it’s now thought that avoiding certain foods like peanuts or eggs may actually increase a child’s risk of being allergic.

Exclusive breastfeeding until the age of 6 months is still recommended. After 6 months, when weaning begins, the government’s food advisory panel (SACN) suggests starting children on peanuts, eggs and any other food thought to have allergic potential as part of the weaning process.

“The deliberate exclusion of peanut or hen’s eggs beyond six to twelve months of age may increase the risk of allergy to the same foods. If initial exposure is not continued as part of the infant’s usual diet, then this may increase the risk of sensitisation and subsequent food allergy”.

So – unless there is a known history of food allergy in the family, peanuts and eggs may be introduced as part of the weaning diet.

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

Dietitians are always looking for new evidence and over the past few weeks in my spare time I’ve been busy researching the science behind dietary fibre for children. I wrote an article in a professional magazine and gave a talk to paediatric dietitians about the benefits of including fibre in children’s diets.

So here’s a quick summary:

What is dietary fibre? It’s any carbohydrate that is not digested or absorbed in the small intestine, and will undergo fermentation in the large intestine. Examples include: fruit and veg, wholegrains, lentils, nuts, healthy cereals.

What’s the point of eating fibre if it’s poorly digested? Fibre has some amazing properties that can assist in keeping normal healthy bowels and general health overall. Fibre in food can thicken the contents of the bowel and mean it’s easier to pass normal stools. Fibre acts as a fuel for healthy gut bacteria and so can help prevent nasty gastro bugs from taking over.

Who can benefit from fibre? Just about everyone can improve their diets to include more fibre. People who are constipated or even have very loose stools can benefit. Research is linking some allergies to the health of the gut bacteria.

Is fibre safe for children? Like any nutrition advice, a healthy balance is the best way to approach fibre for children. Too much fibre is not a good thing, but fibre can be included in children’s diets as they are weaned, and by the time they are two, fibre intakes should be as follows:

2-5 years: 15 grams per day

5-11 years: 20 grams per day

11-16 years: 25 grams per day

17+ years: 30 grams per day

Children need to learn from an early age that fibre is a part of everyday foods and including high fibre foods (such as wholemeal bread) every now and then as part of a healthy eating pattern that will hopefully last a lifetime.

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

Last week I was invited to speak to a group of health professionals who do the amazing job of looking after babies on Neonatal Units across the north west. My topic was ‘nutrition in paediatric palliative care’ – not everyone’s favourite subject but something that does require careful thought and understanding.

In my research for the presentation, I discovered that there are over 49,000 children in the UK living with a life-limiting or life-threatening condition. A recent survey found that 35% of us know someone who has or has had a child with a life-limiting condition.

The charity “Together for Short Lives” is an incredible charity that provides information and support for children, parents, families and health professionals. If you’re interested, I really recommend taking a look at their website (or even getting involved with some of their fundraising activities)… http://www.togetherforshortlives.org.uk/

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

Quite often, cow’s milk allergy goes undetected. Symptoms are either vague, seemingly unrelated and I’ve even heard from many parents that health professionals can label parents’ concerns as being slightly neurotic.

A new tool has been launched which can help parents and health professionals determine whether symptoms are related to cow’s milk allergy. Divided into 5 sections (crying, regurgitation, stools, skin and respiratory), you can rate the severity of each symptom and get a clearer picture of the presenting problem.

Here is the tool: comiss scoring form

Let me know what you think!

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

One of the little pamphlets that arrived in one of my professional newsletters this week was about eating a diet with a low environmental impact. The authors state that sustainable diets are those which contribute to food and nutrition security and to healthy life for present and future generations. Basically, a healthy diet and an ecologically friendly diet has quite a lot in common:

“Eat greener, not too much, and be active” is the take-home message.

So….putting this into practice it means less processed/junk food and more fruit, veg, and grains. Furthermore, reducing food waste and packaging where possible.

I also like this website that is part of a movement towards less plastic:

https://myplasticfreelife.com/plasticfreeguide/

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

The prevalence of osteoporosis is increasing in modern society. Fragile bones make life difficult and painful. We know that our adult bone mass was determined during childhood. Read more

Peanut allergy – potentially life threatening – is on the rise. More people are allergic to peanuts than ever before, and yet this is despite them being a banned substance in many places. Schools, airlines, even cafes and food labels are all hot on avoiding peanuts. Fresh results of the LEAP study might explain why we are more allergic to peanuts, despite being so careful to avoid them.

The Learning Early About Peanut allergy (LEAP) results show some interesting results: children who avoided peanuts had a 17.2% incidence of allergy at 5 years of age, and yet children who were given peanuts in their weaning diet had an allergy incidence of only 3.2%.

Of course, more studies are needed to confirm the results of the LEAP study, but these results may hold the clue as to why peanut allergy is so common right now.

We may not like to admit it, but most of us are probably not able to get through a single day without a hit of caffeine. Tea, coffee, soft-drinks, energy drinks and even some medicines all contain this addictive drug.

Caffeine’s benefits have been known throughout the world for many years: by blocking the neurotransmitter adenosine, which tells the brain when we are tired, caffeine reduces feelings of fatigue. There are so many occasions when the world’s favourite drug can be put to good use: as a morning wake-up, to help with a hang-over or after a late night, to stay alert for an afternoon meeting, for sports performance or even a long drive.

But like any drug, caffeine also has a few down-sides. It has a half-life of around 5 hours, which means the stimulating effects of an after-dinner percolation will still be in full force until the early hours of the morning. It can also induce panic attacks and anxiety in those susceptible. What I find worrying, is that the caffeine in soft-drinks and medicines is almost certainly from synthetic caffeine made in chemical labs in China and the like. Regulating the quality and safety of these is incredibly difficult. What’s more – labelling laws at the moment don’t insist that caffeine levels are fully declared on drink bottles so we really haven’t got a clue as to how much we (or our children) are consuming.

As for children; my advice is to not let children have any caffeine at all. Just in case you think I’m being a little over cautious, here is a quote from a report in 2011 on caffeine from the American Academy of Pediatrics: “Rigorous review and analysis of the literature reveal that caffeine and other stimulating substances contained in energy drinks have no place in the diet of children and adolescents.”   

The summer holiday season is upon us, and I am often asked about using bottled water to make up infant formulas when abroad.

There are three different sources of water: tap water – contains chloride and fluoride with all other minerals removed during the treatment process, bottled water – which is expected to conform to the same standards as the public water supply, and thirdly natural mineral/spring water. Mineral or spring waters may contain higher amounts of solutes including nitrate, sodium, fluoride and sulphate. Waters with high mineral contents are unsuitable for infants and young children.

Recommendations for using water abroad:

1. Use tap water which has been boiled once and allowed to cool to between 70-80 degrees Celsius before adding infant formula. In countries where the tap water quality cannot be guaranteed, bottled water can be used an alternative.

2. Use bottled water which conforms to the UK Dept of Health guidelines: (maximum amounts) sodium: 200mg/litre, nitrate: 100mg/litre, nitrite: 3mg/litre, sulphate: 500mg/litre.

3. Avoid using all water in bottles labelled ‘natural mineral water’ or ‘spring water’.

And happy holidays!

Many of my friends and colleagues know that I’m very interested in Vitamin D. I attended a professional update on Vitamin D in London last week and was excited to see a couple of new developments: a vitamin D supplement that comes in a mouth spray (tablets can be hard to swallow especially for children) and also an online vitamin D calculator. Dr Benjamin Jacobs has helped develop the online tool as part of the Vitamin D Mission. The website is worth checking out: Vitamin D Mission – especially the calculator and the printable posters that I will try putting in some of the schools and nurseries I work with.

As for the mouth-spray supplement: I’m pretty sure kids are going to love it. Made by BetterYou.

I was inspired after meeting a top junior athlete today to write about nutrition for athletic children.

I am an athlete myself and have competed for several years – sometimes at an elite level – as a runner. I also work as a sports dietitian and work with young talented athletes mostly via a talent program at Loughborough College.

Maintaining adequate nutrition in athletic children is so important for their general health, growth and development, and to ensure they perform well. Not keeping up with energy requirements will mean the child becomes tired and lethargic and also risks injury, immune system assaults and even poor growth.

Children who are constantly on the go need to ensure they eat regularly to top up their energy levels. Eating enough can be difficult – especially if training or competing gets in the way of meal times and if food immediately prior to exercise causes some discomfort. Careful planning of meals – even if it means heating up leftovers or making use of your freezer – mean that a healthy meal can be eaten to ensure good recovery after training. It is all too tempting to stop at a fast-food outlet instead of having a ‘proper’ family meal containing good quality carbohydrate, protein and vegetables. Taking nutritious food and snacks to sports events also means that the ubiquitous burger van isn’t the first port of call on a day out.

Hydration is also really important for junior athletes – children can’t regulate their body temperature quite as well as adults, and can also get very distracted – missing their initial thirst cues. Make sure you send your child to school with a water bottle and encourage them to drink regularly. And yes, water is best!

Finally, supplements such as energy gels, protein bars and sports drinks are not made for children. I don’t encourage children use these and worry about how vulnerable junior athletes are to being mis-sold these products that have the potential to do more harm than good.

It’s that time of year again – leaves are falling, days are getting shorter, summer holidays now long forgotten….and our vitamin D levels are about to plummet.

If there’s one vitamin I recommend for all children, it’s vitamin D.

We know that British toddlers receive less than 30% of the recommended amount of daily vitamin D from food – the rest must come from exposure to sunshine in the summer. In the winter, sunshine levels in Britain just aren’t strong enough for our bodies to synthesise any vitamin D, so for children 6 months to school age (some would say beyond) a vitamin D supplement is a must.

Vitamin D is crucially important for strong bones, growth, muscle development and the immune system. Vitamin D has also been implicated in other serious medical conditions such as type 1 diabetes, hypertension, cancers, multiple sclerosis (MS) and the autistic spectrum disorder (ASD). Severe vitamin D deficiency in children results in bone softening or “rickets”.

Vitamin D drops can be found in your local supermarket or pharmacy, or some NHS clinics supply the drops too. I remind parents to keep the bottle on their kitchen top or in a place where they won’t forget to give their children their daily dose. Vitamin D should be given all year round – not just in winter. Let’s face it – the amount of sunshine in the British summer is sometimes variable and often outside play is difficult.

As a dietitian, I usually steer well clear of popular diet books, the latest diet fads or celebrity weight-loss plans. You might think this is akin to burying my head in the sand – but I really dislike spending any time thinking about diet crazes and worry about how certain foods or nutrients are the flavour of the moment one minute…then blacklisted the next. Carbs were once good, then they were out and protein was in, then superfoods found a place, now calorie counting is back – it really is all pretty ridiculous.

Finally though, I’ve found a book (and let’s not call it a ‘diet book’) that almost exactly outlines my own diet and nutrition thinking. Michael Pollan is an American journalist and has written a neat little book called “Food Rules”. (I’m not going to put any links in here, as I really and truly am not trying to sell it). His wisdom is summarised by the three sentence rule: eat food (as in real food – no imitations, chemical-laden, processed crap), mostly plants (yes of course fruit, veg and wholegrains get the thumbs up) and not too much (easier said than done, but some helpful reminders all the same). Expanding on this – in 64 ‘rules’ he forms the basis for every eaters’ life-long dietary guidelines for surviving the Western diet. Examples include: “avoid food products containing ingredients that no ordinary human would keep in the food pantry”, “avoid foods you see advertised on television”, and “treat treats and treats”. The advice is written in a light-hearted way; yet following it is a simple way to navigate the labyrinth of diet programmes, advertising, government policies etc and just have a sensible healthy diet.

If there’s one food book to have handy for your supermarket shop – I certainly recommend “Food Rules”. I can’t say following it will be easy, but then diets aren’t supposed to be easy are they?!

Hayley Kuter – paediatric dietitian

www.blossom-consulting.co.uk

Not enough vegetables are eaten by children. We know that from thousands of studies across the western world, and it’s evident from our rising problems with obesity in this country. Vegetables are low in energy and dense in nutrients – which makes them a very important part of children’s diets.

The main trouble is actually getting a child to like vegetables and to eat them.

The European project ‘HabEat’ has studied different methods of making children like vegetables – without force, bribery, or punishments! The three ways they researched were:

1. Repeated exposure to the vegetable – at least 8-10 tastes

2. Adding a flavour (sweet or savoury) to the vegetable

3. Adding energy (eg ketchup) to the vegetable

Overall, the results showed that the technique of repeated exposure is the most effective for increasing vegetable consumption in children of pre-school age, especially since this means not adding ingredients which are not in line with public health recommendations (sugar, salt, sauces, etc).

Interestingly, adding energy (eg ketchup) showed no positive results in the consumption of vegetables in the long term.

Hayley Kuter

Paediatric Dietitian

www.blossom-consulting.co.uk

I’m always trying to find a good source of tried, tested and reviewed recipes that are allergy-friendly. By chance today I’ve come across PigIntheKitchen – a blog with a host of recipes for dairy, gluten, egg and other allergies. The gluten-free, egg-free, milk-free carrot cake looks amazing – I can’t wait to try it myself. Happy baking!

With the 2012 Summer Olympics and Paralympics now drawn to a close, we can reflect on both the success of these amazing sporting events and some of the controversy that surrounded the games beforehand; from the amount of money spent, to the sponsors being purveyors of high calorie junk food and drinks companies (I’m not going to name them here to avoid further advertising!).  Hopefully now that the games are over, we will all feel inspired to leave our sofas and particpate in some sporting activities ourselves. The Lancet  has published studies to show that inactivity is a risk factor comparable to smoking or obesity.  Further studies have shown that cutting down on tv time can increase our life expectancy by 1.4 years, and that restricting the amount of time someone spends sitting down to less than 3 hours per day could increase life expectancy by 2 years. Obviously our sporting heros are highly trained, committed, talented and competitive – but perhaps we could be inspired on some level to do a bit more exercise – not just for the sake of our waistlines but for the prevention of many other diseases and of course that ‘feel good factor’. Happy moving!

Texting whilst at the dinner table, not washing hands before a meal, and scoffing food in a hurry are all examples of the table manners in decline as found by a survey at the recent Birmingham Food Fest (July 13-19). The tradition of eating as a family, and savouring the meal in front of us has become rare – with our busy lives, social media and other distractions taking over.
As a paediatric dietitian, I often see families who don’t manage to eat meals together, or allow the tv on, games and other distractions to take over from the main event. Does this affect nutrition? Of course!
Food is such an important part of family life, and of nutrition too – and this survey perhaps highlights the need for back-to-basics approach to mealtimes and eating. The Birmingham Food Fest website offers a guide to table etiquette: Good Etiquette Guide
– perhaps a good start to re-establishing values that seem to have been dropped.