Beth: Good evening everyone and welcome to this evening’s twilight online Infant Feeding and Healthy Growth Conversations. My name is Beth, your host for this evening. We are joined tonight by our presenters, Professor Elizabeth Denney-Wilson and Dr Linda Mann. Before we get started I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. We pay our respects to the Elders past and present.
Tonight our presenters are, Professor Elizabeth Denney-Wilson and Dr Linda Mann. Elizabeth is a Professor of Nursing at Sydney University and conducts research into the primary and secondary prevention of obesity, especially in families with young children. She works with GPs and nurses to develop and trial brief interventions that can be used in primary care. She recently completed a trial of an App to support healthy infant feeding and promote healthy weight gain and growth. She is part of the Early Prevention of Child Obesity Collaboration and her team has been awarded an NHMRC grant to roll out a child obesity prevention intervention across Victoria.
Linda is a Fellow of the RACGP and a member of the RACGP Antenatal and Postnatal Care Network. Linda has both local and international medical experience, especially in genetics and women’s health. She is the GP representative on various national and local government committees and is an experienced medical educator.
Linda: By the end of this online QI and CPD activity, you should be able to be aware of infant feeding behaviours associated with rapid weight gain and childhood obesity in infancy, assess growth in zero to two-year-olds and identify rapid weight gain using the weight to length charts. You should be aware of current guidelines and recommendations for infant feeding. You should be able to provide advice to parents about best practice formula feeding including how to feed, the difference between formulas and what to look for when choosing a formula and you should be able to discuss infant growth with families and utilise available resources to provide advice to families about infant feeding.
So, to start this evening, we thought we would like to ask you some question. And the questions are, do you think it is appropriate to discuss excess weight gain in zero to two-year-olds, and do you talk to families about healthy weight gain in zero to two-year-olds? Let us do the first one first as a poll. So the first is, do you think it is appropriate to discuss excess weight gain in zero to two-year-olds?
Beth: So, 84% of you believed that yes, that it is appropriate to… sorry what was that question?
Linda: To discuss weight gain in zero to two-year-olds.
Beth: Thank you. And 5% believed that no, it was not appropriate to discuss excess weight gain. And 11% were unsure.
Linda: Okay. Let us try another poll. Do you talk to families about healthy weight gain in zero to two-year-olds? Interesting.
Elizabeth: Very interesting. Well, I guess we should get started and see if we can convince anyone otherwise, Linda. So this webinar tonight has been developed in collaboration with New South Wales Health and what this diagram shows, is the relationship between the Healthy, Safe and Well Strategic Health Plan. This provides an emphasis on the first two thousand days framework and all of the different health service policies fit under this health strategic policy. So for children to have the best possible start in life, families, carers, early childhood educators, communities, health services and professionals need to understand the importance of the first two thousand days and use the information to make decisions about how they can support better outcomes in the first two thousand days. Now obviously GPs are absolutely pivotal in terms of providing this support in the first two thousand days, so that is really just trying to put this webinar in context and why New South Wales Health are taking such a keen interest in working with GPs in this space.
So just to have a quick snapshot of where we are at in terms of childhood overweight and obesity. We have had a number of studies that have been done over the past 10 years or so. All the New South Wales schools, physical activity and nutrition surveys, obviously these are done in school aged children. What they have shown is that the prevalence of childhood overweight and obesity doubled between 1985 and 2004, but the rates are now pretty stable.
Linda: So, we are winning the fight, then?
Elizabeth: Well, we are winning it certainly in some areas, Linda. So, what this hides is that in some demographic groups, in some socioeconomic groups, the prevalence is actually increasing but it is declining among more advantaged populations. So am sure a lot of you would be thinking, well I certainly see more than one in four kids in my practice who are overweight or obese, so it is indeed the case that among some cultural groups and in some areas, we are seeing many, many more children who are overweight or obese.
Linda: And sometimes the difficulty is the parents’ understanding that their child who they think is fat and healthy, is actually obese.
Elizabeth: Absolutely, and I guess that is a whole other webinar, but it is really important to understand that some cultural groups have a real preference for babies who appear as they might say –
Linda: Fat and healthy.
Elizabeth: Indeed, thank you. Yes. So weight gain starts early and once it is with us it is difficult to reverse. So one of the really sticky risk factors that is associated with overweight and obesity is rapid weight gain in the first year of life. And this is how rapid weight gain is defined, is the crossing of growth centiles on a weight for length chart, and I know you are all more than familiar with growth charts. So, one in four children who are between two and four, so prior to school starting, are already above a healthy weight. So that reflects this, sorry I was expecting a click… Okay we have got a slight slide malfunction in that we were expecting to see a couple of circles showing you that there are a couple of periods that are really crucial or really critical, and one of them is the two to four-year-old age group, and the other one is the late adolescent and early adult group. So you start to see an increasing rate of overweight and obesity. This is not to say that overweight and obesity cannot develop at any age, but when it does develop in the first year of life or in that pre-school period or in late adolescents it tends to be more persistent. So it is really important that we keep a close eye on children across their whole age.
Linda: So we might think about measuring heights and weights, a bit like measuring blood pressure in adults. We measure the blood pressure of adults whether we think there is a problem or not, because we need to know how things are going over time.
Elizabeth: Exactly. And blood pressure might tell you something at a single measurement, but what is important about growth is that you actually see several measurements over time, because then you really get a picture of what is happening with each child.
So just to go back to rapid weight gain again, so remembering this is now defined as crossing growth centiles obviously in an upward trajectory. So this has been something that has become of great interest over the past few years and there have been a number of studies. And indeed a systematic review that was done of 21 studies found a positive association with later obesity. So this is obesity in later childhood and indeed in adulthood. And showed that the increased risk was somewhere between 60% and 200%, and the studies that were published after 2000 showed a greater risk. So, that is of course when we started to see many, many environmental changes around overweight and obesity. There are similar effects in low and normal birth weight infants and we will talk a little bit about low birth weight infants a bit later. And then if you look at modifiable risk factors, so these are things like high maternal BMI, increased weight gain in pregnancy, smoking in pregnancy, here we saw that rapid weight gain was associated with obesity in 45 out of the 46 studies. So I think we can say that it is a definite risk factor that we would want to be keeping a close eye on because of later risk.
Linda: So that two thousand days, that is after the birth, isn’t it?
Elizabeth: Yes. So two thousand days is from conception to five years.
Linda: So it is conception. So the reason I am asking, is these modifiable risk factors in fact affect that two thousand days.
Elizabeth: They do, indeed. And I guess another thing to just think about in terms of those first two thousand days is that we also know that babies who are born vaginally seem to have some protection, and that seems to be because of the gut biomes, so you know, the gut biome seems to be really important in terms of later overweight and obesity as well.
So there are a number, obviously babies have to be fed. Fed is best. But there are some feeding behaviours that are associated with weight gain.
Linda: Hang on, what do you mean, fed is best?
Elizabeth: Well, of course we need to feed our infants.
Linda: So this is to stop the stigmatising of a particular form of feeding?
Elizabeth: Well yes and we know and we will talk a lot about breast feeding. And breast feeding is far and away the best way to feed infants, but one thing that mums who formula feed report in numerous surveys, and indeed we have just finished a study looking at this, mums who are formula feeding report that they find it harder to find information and to get support around their feeding decisions. So we really need to be mindful of that I think and support all parents.
So let us just talk a little bit about the feeding behaviours that have been found in cross-sectional and longitudinal studies to be associated with weight gain. So, the mechanisms are not completely clear, but it is much more common in infants who are bottle fed, particularly with infant formula, but the sort of rare baby who is fed breast mild through a bottle, exclusively through a bottle, is more likely than an exclusively breast-fed baby to have rapid weight gain. But certainly rapid weight gain is really much more common in babies who are fed with formula. Babies who are fed to a schedule rather than according to their hunger and satiety cues, and who have early introduction of solids before four months, and who are fed to settle. So, this is a really important thing to think about, because we know that interventions that aim to help to teach and help support parents to find other ways of settling their child other than feeding, seem to be associated with reductions in rapid weight gain.
Linda: Elizabeth, you mentioned small for dates babies, but I have got a different question. And that is about premature babies. Because premature babies when you chart them, you kind of start to chart earlier than the chart. So both of those groups, how do we understand when it is time for them to sit in ordinary charts?
Elizabeth: Yes, look this is a really important question, and there is some emerging evidence. It has not been done well enough, but there is some emerging evidence. So, obviously in premature babies, there is a trade-off between wanting them to have rapid weight gain, to improve their cognitive development, and being concerned about the risk factors for overweight and obesity. So what the evidence seems to suggest is that by four months, so you would hope to see good solid, rapid weight gain, or very rapid weight gain.
Linda: Because that is catching up.
Elizabeth: Exactly. In the first four months, so that they do catch up. And that is positively associated with IQ scores later on. But by four months, you would be hoping that they would be starting to sit on a growth curve and to start to follow that a growth curve. And that then is reducing their risk of overweight and obesity. But in all children, in all infants, so those with prematurity and also those born at term who are of a healthy weight, the real key here is to talk to families about their feeding behaviours. So, it is not just what to feed but how to feed. So here we have been thinking about, are you feeding the baby when they are hungry? Are you stopping that feed when they have had enough? So, I think we have all seen the bottle fed baby whose mum has made up 100 ml of formula because that is what it says on the side of the tin, and then jigging that baby around and changing sides and doing everything they can to get that bottle to finish.
Linda: And what about breast-fed babies? Do they have the same difficulty with signals to say they have had enough?
Elizabeth: Now see this is one of the really, another beauty of breastfeeding, is that breast feeding parents learn to trust that if the baby is growing, if they are having wet nappies and the right number of wet nappies, and you know, a couple of good stools a day or a few stools, or a week, yes indeed, that their baby is having enough. So they trust, they learn to trust the baby’s inbuilt hunger and satiety cues. So a lot of the research around formula feeding and obesity risk and rapid weight gain, is around this interest in the inbuilt hunger and satiety and whether by forcing baby to finish that bottle, we are actually overriding their natural ability to regulate their intake.
Linda: I am just addressing a couple of questions that have come up. You have talked about not giving a baby a bottle to sleep, what about breastfeeding your baby to sleep. Does that carry the same concerns?
Elizabeth: It does not seem to carry the same concerns and it is possibly again, because of that same mechanism around hunger and satiety, because breast fed babies who are fed to sleep, will usually doze off to sleep, like as soon as they have dozed off to sleep, mum will then pop them down into the cot. And so again, they are essentially saying to mum, I have fallen asleep now. I have had enough to eat. Whereas again, if you have made up that bottle with however many ml it is, well for lots of reasons but you and I probably grew up in the age when we were taught to finish all the food on our plate, well I think there is a real instinct that parents have that they should be finishing all of that bottle.
Linda: So, we have talked about assessing people. Did I hear you say that you use weight versus length charts? Because most of us use age versus length and age versus weight.
Elizabeth: And indeed, those are the most commonly used charts, so weight for age and length for age. The charts that are in the blue book and the charts that are in MedicalDirector and the other desktop software. So that is indeed what most people use and those are the charts that I think we will be mostly talking about tonight. There are certainly weight for length charts, but they are not used as frequently in the nought to two-year-old age group.
Linda: So we GPs do not have to stress about that?
Elizabeth: You do not have to learn a new chart, no.
Linda: So audience, now we are talking about measures, when would you do lengths and weights? Would you like to write into your chat box and give us some ideas? So there are a mixture of people who use the blue book and vaccinations as a stimulus. Some people use it for medications, because you would like to know the weight. Some people do it every visit. And some people do it every visit until 12 months. So, most people have a sense of what they are up to and what they are going to be doing from that point of view.
Elizabeth: Yes, great. So one of the things we find is that sometimes babies do not get their weight and length measured unless mum raises the issue, so sometimes mums really as you know, worry about growth. But what we would suggest is that length and weight are measured at every visit. And it is much more important to, it is really important to have two or three or four, or multiple points of reference so that as soon as we can see that something is changing, in whichever direction, then there is an opportunity to intervene. So if you do not measure, you have missed that opportunity.
Linda: So many of us will have digital scales. If you do have digital scales, please make sure that they are calibrated. You would know that we recommend that people use these, what you can see on the left there, are they called stadiometers as well? The ones for lying down as well as the standing up one?
Elizabeth: That is a really good question. I have always called them length boards.
Linda: Length boards. They are the sort of things, the ones we have got are not a board, they are actually like a piece of cloth with two nice things at the ends for the head and the feet. I have to say though that I think personally, length is a very moveable feast depending on how unhappy the child is.
Elizabeth: Yes, moveable feast is the term, isn’t it? Yes. So look, I guess there are certainly challenges with measuring babies’ length, but this chart here is an example of the charts that are available for free on the healthy kids for professionals website and can be downloaded as often as you like, and there are lots of resources we will be referring to tonight that are available on that website. The important thing is that you do measure the child lying down, you do your absolute best to get them to stay as still as you can. But, just understanding that it might not be quite, you know.
Linda: How long should they stay lying down? I mean most kids are standing up in a reasonable fashion at 12 months.
Elizabeth: It is not until two that you should swap to standing for measuring length. So sometimes you will see just a tiny dip at two when you swap from lying to standing but that is of course nothing to worry about. Measurement error.
Okay, so these are the growth charts that we have talked about before and you can see that these are the growth charts that you will be most familiar with so the weight for age and the length for age, and you can also see really clearly these centile lines marked. So, this is what we were talking about before when you are plotting a child’s growth you will see that most children will pretty much follow a line that is parallel to one of the centiles, or sit on the centile and it is when they start to cross centiles that we start to worry about rapid weight gain.
So, it is important that all health professionals should regularly assess a child’s growth, so in this age group not just GPs but your practice nurses, child and family health nurses. But what we know is that even though sometimes GPs and nurses are really reluctant to raise the issue of weight because they do not want to offend.
Linda: Especially if the family is big in itself.
Elizabeth: Absolutely. And particularly if the family is big, or indeed if you might be concerned about your own weight. But it is particularly important that it is raised, because studies with parents have found that parents actually expect it to be raised. So sometimes parents will express real surprise if it suddenly raised and the child is four or five, or six and it has never been raised by their GP. So they trust their GP, they are more likely to, they may not change their behaviour immediately but they are certainly more likely to think about changing their behaviour and take advice.
Linda: It is a bit like smoking. Because we know that every smoker actually expects a GP to do the job of saying, okay, I see you are smoking. How do you feel about that? Have you thought about stopping? Because every smoker has always thought about stopping. And smokers we know from evidence do not get insulted. Like you said, they expect the question to be raised. So you are saying that we can talk about the baby’s weight and their growth?
Elizabeth: Their growth, yes. And indeed, yes so parents expect it. They expect you to mention it and if you think there is an issue, and even if you cannot, obviously in a busy general practice on a busy day, you may not have time to talk about growth at every visit, but if you can weigh the child and measure the child at every visit, then when you do have a spare five minutes, you can initiate the conversation if you see that trajectory might be changing. So, it may not be possible to raise it at every visit, but it is certainly important to raise it at some stage.
Linda: So in order to have some idea about what I am going to talk about once I raise these issues, I have to say I personally do refer to the Infant Feeding Guidelines because I am sure the audience would agree that things change from time to time in relation to guidelines. You could not tell from that beautiful picture at the front, but I actually have grey hair. It is a long time since I knew about infant feeding from the seat of my own pants. So rather than use my vast experience, it seems to me quite reasonable that we should think about using the Infant Guidelines and the summary is actually reasonably well written. Many of us would know that, for example the advice about solids changed over time.
Elizabeth: Changed between my two children. So, yes.
Linda: That PDF I think is one of the things that is downloadable. It will be in the handout section of the bar on the side of your computer. If it is not and you do not have it, there will be an email connection at the end of the talk and you can ask for it.
Elizabeth: Yes, these are great things to refer to. They are evidence based, they are updated every few years, so they really do contain a great source of information and support.
So we are just going to talk about breast feeding for a bit. We have a National Breastfeeding Strategy, in Australia we have pretty good initiation rates of breast feeding, in the 90%, but our breast feeding rates do tend to drop off quite quickly in that first sort of month after birth and there are a number of strategies that are being discussed and to increase that duration of breast feeding. And it is important of course for all health care professionals to be supportive in promoting breast feeding. So, even if it is, some breast feeding is better than no breast feeding, but obviously exclusive breastfeeding provides the strongest evidence in terms of benefit. So, breast fed babies will often grow more rapidly than formula fed babies in the first few months, but then it tends to settle down and so long as they are having regular increases in weight, length, head circumference, and having some…
Linda: Developmental gains.
Elizabeth: Exactly. Then we can be confident that they are getting enough to eat. So there is mixed evidence about the effect of breast feeding on obesity risk. Most of the studies have been in populations that are well-educated and who you would expect to have a higher prevalence of breast feeding anyway and who would be less likely to experience overweight and obesity, but the numerous other benefits outweigh any concern that you might have about breast feeding.
So the recommendations around breast feeding are that we encourage or promote exclusive breast feeding to around six months of age and that we continue breast feeding but introduce appropriate solids at around six months and really, breast feeding can continue for as long as the mum and the child desire. So there are benefits for mum and lots and lots of benefits for the baby, and I think we are all very comfortable with that, aren’t we?
Linda: Yes. What we are less comfortable I think, if giving advice about formula feeding, because most of us have had no formal instruction in how to choose the right one or the care and handling of such things.
Elizabeth: Yes, and it is something that we are not as well trained in. And even, it is just not common to have training around formula feeding. So, in terms of seeing someone who is formula feeding, it is important that they are offered support. And we really want to offer the support, particularly around how to feed, not just what to feed. The recommendations are that we use cows’ milk based formulas until 12 months of age and many of you would probably be familiar with the stage 1, stage 2, stage 3 formulas.
Linda: Those marketing characteristics, a bit like special analgesics for special complaints.
Elizabeth: Exactly right. Exactly right. So, one of the important things to think about in terms of infant formula, is that infant formula with high protein content has been associated with rapid weight gain. And this is a really tricky one I think because, if I were a parent swapping to infant formula, and I was looking at nutrition labels, just say, and I saw high protein versus low protein, I am going to think, oh protein, oh that is good, so I think I am going to go with the high protein.
Linda: Build my baby’s muscles.
Elizabeth: But what we know is that in the higher protein content formulas, the protein is actually of a poorer quality, and indeed it is associated with rapid weight gain and with greater risk of overweight and obesity. So, we see higher protein content in these stage 2 formulas. So, the infant feeding recommendations are that you need stage 1 formula. You can feed that stage 1 formula and those are whey protein based which is a bit more like breast milk. Those are suitable for babies all the way up to 12 months, and at 12 months you swap over to cows’ milk in a cup. So get rid of that bottle.
The stage 2 formulas, I mean I am not a marketing person Linda, but I strongly suspect that that is about keeping you brand loyal, giving you a new thing to try. They do have higher protein content and so they are sometimes marketed for hungry babies because there is the thought that the casein based protein might sit in the tummy for longer. There is no real evidence around that, but that is the marketing claim. And then probably, I am sure you have all experienced this, that you get parents saying, what about the stage 3 formulas? Or the toddler formulas?
Linda: Oh, the toddler formulas.
Elizabeth: So, the toddler formulas are really nothing but a marketing ploy. They have less protein than cows’ milk, good old cows’ milk from the supermarket. They are more expensive than cows’ milk and they are often thickened and have additives like corn syrup which we really, really do not need. So there is really absolutely no need for parents to be guilted into thinking that they need to introduce a toddler formula to their child.
Linda: You know, I will tell you something. At 12 months when I am doing the 12 months check, I asked every single parent now since I have been exposed to this information, I say to them what are you feeding the child now? And they may be breast feeding, may be formula feeding. And I do not ask them what are you going to do? I say, what are your plans to introduce cows’ milk? Will you be using a cup? And if they say well, we were not going to use cows’ milk, we talk about the difference. It is interesting how many people think that I will just finish the formula I have got for the next three months and then I will move across, to which my response is, really? You are going to say $12 for the sake of your child’s health? That does not sound like the sort of person I thought you wanted to be as the parents of this child. It is interesting when you directly ask what the plans are for changing over at 12 months, people’s response. And clearly, one of the things that we do, is we give permission to parents to make the choice that we are suggesting. And this is part of that countering the advertising.
Elizabeth: Which is hard.
Linda: And also, responding to that evil group, the mothers’ group, because you know if you want to have some idea about how to guilt or shame people into interesting behaviour, it is talk to a group of parents who make one or two people feel uncomfortable about what they are doing.
Elizabeth: Yes, indeed. So I am just going to quickly touch on talking to parents about the importance of correctly preparing formula. Because every formula tin, every brand has a different size scoop, so it is important to use the scoop that came with that tin, and it is important too, that the scoop be just loosely packed. So we looked at common formula preparation errors in one of our studies, and the most common error was actually pushing, you know really firmly packing the formula into the scoop. And of course that means that the baby is getting more calories than they need. So, one of the things that I am really sort of interested in, is that when I first started in this game some 20 years or so ago, the thing we used to really worry about in formula feeding families was that they were diluting the formula to make it last longer. But now what we worry about is parents putting extra formula in the bottle on the assumption that it will actually help them grow better, but what it will actually do is help them grow too much and experience rapid weight gain with all its risk factors later on, but also there is no evidence that it will improve their sleep. There is no evidence of any of those sorts of benefits, so it is really important that parents follow the preparation instructions that are listed on the tin.
So I am going to keep talking about bottle feeding a little bit.
Linda: One thing, you said people used to dilute formula to make it go further. I do specify to parents who come in with their children, if their child is sick and you feel that they need more fluid, that you give them some water. You give them normal strength, properly made up strength of formula, and you give them water. And one of the other things, there is a question in the blue book and I think there will be people in the audience who have not thought that question had validity, which is, has your child had anything else except milk or breast milk, I forget how the question is worded. In some of the more remote places that I have worked, one of the things we teach mums is not to give their children tea in their bottles because tea is the culturally appropriate drink and it is not appropriate at all for babies, nor is fruit juice, nor sweet drinks, and you may be surprised that that is a thing that is worth mentioning just so people are sure that that is not what we want that child to have.
Elizabeth: Yes, absolutely. No question about that. It is common in some cultures, isn’t it to introduce different fluids other than infant formula. So for that first six months of life, breast milk or appropriate infant formula.
Linda: What about water? How old should they be giving babies water?
Elizabeth: Well, we can give cooled boiled water from about six months. But again, at six months you would be giving it in a cup. So you would not be giving it in a bottle.
So the other thing I wanted to talk about, is again around how to feed. When a mum is bottle feeding, or a dad is bottle feeding, we want to do it in a way that mimics breast feeding because we know that there are other kinds of benefits to breast feeding around cognitive development and development of sight and nurturing behaviours and all of those great things you get from the act of breast feeding. So, when a baby is bottle fed, what we want to see is that there is still that holding of the baby at the breast. That we are controlling the flow, we are holding the bottle. We are looking into bub’s eyes. We are smiling at baby, we are looking at them in a loving fashion and what we are not doing, is propping up the bottle with a cushion or a pillow.
Linda: While they are looking away.
Elizabeth: Yes. And one of the really alarming things I saw at the obesity conference that I was at last year, was a special contraption that you can actually get to put on your IPad and it holds the bottle while you are busy, you know, playing on your IPad and paying absolutely no attention to your child at all.
Linda: I thought the screen limitations were about the baby’s development.
Elizabeth: Yes. So obviously it is a tricky one. You know, mums and dads need to remain connected to their friends and family and that sort of thing, but if they could pop the phones away while we are doing the feed, that would be incredibly beneficial for baby’s development as well as that bonding.
Linda: So one of the questions is, is it okay to put baby to sleep while breast feeding, but not with a bottle? I think we addressed that one.
Elizabeth: Yes, so one of the things about breast feeding is that baby does get to still determine their own hunger and satiety. And so mum breast feeds the baby and as soon as the baby falls asleep, they are popped into bed.
Linda: So it is a different scenario.
Elizabeth: It is a different scenario. Whereas if you are using a bottle to bed, what often happens is that baby is handed the bottle so that the baby is feeding themselves to bed and they are also going to polish off that whole bottle whether they need it or not. And we do not want that because that is really giving them more milk than they need, more calories than they need.
Linda: And just to tease this out a bit longer, for mums who are breast feeding babies, they breast feed their babies for the length of time they want to do so. If that is less than 12 months, they make up the difference with formula before converting to cows’ milk at 12 months? That is what we have in mind?
Elizabeth: Yes. And it is perfectly okay to use the stage 1 formulas. So not to get caught up in the marketing hype, but to use stage 1 formulas that have a lower protein content and those are perfectly fine to use.
Linda: So even if it is for a month or two.
Linda: And then convert to cows’ milk.
Elizabeth: Exactly, at 12 months. That is exactly what the Infant Feeding Guidelines say. Yes.
So we are going to talk a little bit about introducing solids, so this is one of the things that would have changed from when we had our babies, Linda.
Linda: Changed back and forth. I have to just share this with you. A hundred thousand years ago, I actually worked at the age of 16 as an assistant in nursing in a large Sydney hospital. And we introduced Farex at six weeks in those days. I just had to share that.
Elizabeth: Yes. Well, we certainly do not recommend that any more. So at around six months of age, certainly not before four months, but around six months of age, iron rich foods are the first foods that are recommended to be offered to babies. So this includes iron enriched infant cereals, pureed meat, poultry and fish which are all good sources of iron. For our vegetarian families, cooked tofu and legumes, and then we would offer, next in line we would offer vegetables, fruits, dairy products such as full fat yogurt, cheese. They can be added next. Now, some babies will take half a teaspoon. Some babies might want a bit more. And you will see on that slide it talks about a serving size and a rough guide to serving size is the size of your fist. But it does not mean the size of your fist, it means the size of the baby’s fist. And this is just a bit of something to keep in mind, because again, often parents do not know what a serve looks like, and so giving them that visual, that that is about how much baby should be eating in terms of solid foods once solids are established, obviously not in the beginning when you just do tastes. But also important to remember that we continue that breast milk or infant formula to 12 months, even after solids are introduced. But yes, starting solids around 12 months is what the recommendations suggest.
Linda: I want to reiterate, there are other sources of iron apart from meat. There is a very large country called India where an awful lot of people have been vegetarian for a very long time.
Elizabeth: With very good health, indeed. Just in terms again of that hunger satiety thing that I have been talking about quite a lot. It is up to the parents to choose the high quality solid food we are going to offer to our babies, and then to prepare a portion when solids are established that is around the size of the baby’s fist. But if the baby is showing all of the signs of being full, so moving their head around, closing their mouth, all of those things, then we are going to suggest that they stop that particular feed. We are not going to force the child to keep eating.
In terms of texture of solid foods, we want to increase the texture and get them up to eating some of the family-type meals by about nine to 12 months. So this is an example of how we might offer food. So it is kind of mashed and a bit pureed at six to seven months, and then it is really just mashed and then we are looking at food that looks like family food by 12 months, nine to 12 months.
This is another example of those really great resources that are available on the Healthy Kids for Professionals website. So, these are the two resources that are particularly applicable for babies nought to 12 months, and then 12 to 24 months. And the important thing here that we are emphasising is that we are all eating together as a family. And these resources can be used not only to assess what might be happening at home with the baby, but also as a way of providing advice and suggestions.
Linda: One of the nice things about this, is you do find families where all the responsibility is for the mum and the dad may or may not be there for dinner and is not there to help, the encouragement that is in these documents is very family oriented and may be helpful for women who are struggling to involve the male members of their families.
Elizabeth: Yes. And there is lots of evidence around the importance of family meals in terms of reducing overweight and obesity risk.
So, one of the questions we got last time we did a webinar on this topic was around allergies, because I know that that is something that you see a lot in general practice. So what is really important is that a few years ago, a couple of years ago, there was an Australian consensus on infant feeding guidelines. So this was because there had been some confusion between the allergy groups and the infant feeding guidelines groups about when to introduce solid foods. There were some people who were thinking it should be earlier rather than later, but there has been consensus now. And so what all of the groups agree on is that we introduce solids at around six months and that some potentially allergenic foods can be introduced after six months. And these include the nut pastes and spreads, and obviously you introduce it in really tiny amounts.
Linda: Does it make a difference if you put it on their skin rather than their mouth? Which is one of the things people sometimes do if they are worried.
Elizabeth: Yes, my understanding is that in the mouth is where we want to be putting this because that is where it is going to be most frequently ingested. Certainly I guess if the child is feeding themselves it might end up on the skin.
Linda: And when we say cooked egg, we are talking about egg white and egg yolk?
Elizabeth: Yes, that is right. That is right. So, but there is little evidence in fact, there is little evidence that delaying solids beyond six months reduces the risk of allergy, and in fact there is some evidence that it goes the other way, that delaying introducing foods may in fact increase rather decrease the risk of allergy. So following this consensus guideline is what we do and we have included that in the handout.
Linda: Now, can I just, we are going to sort of have to move through this, but I just want to ask one particular question. You have written unsuitable foods for infants includes plant-based milk substitutes. So that is your soy and your almond and all those things that I think should be called juices rather than milks, personally.
Elizabeth: Yes, and this is certainly a question we got when we had a Conversation article a couple of years ago. This is the main point that was hammered home to us in the comments, that the Infant Feeding Guidelines are really clear that plant-based milks, because they do not have the protein content or the calcium content of cows’ milk are not in fact called substitutes at that 12 month mark.
Linda: So if you are moving over into cows’ milk, it is cows’ milk, not soy.
Elizabeth: Indeed. It is cows’ milk. Yes. I mean unless there is some…
Linda: Well if there is medical reasons for doing it, that is a different conversation and whatever doctor has identified that particular form of allergy, well no doubt.
Elizabeth: But yes, full fat cows’ milk is what we are aiming for.
Linda: So I would like to introduce us to Olivia. Olivia is 15 months and she weighed 12 kg and is 77 cm tall but measured by lying down. You plot her weight and height and find she is on the 96th centile for weight and 50th centile for height. So you are a bit concerned about this mismatch. What should we do Elizabeth?
Elizabeth: Yes. Well there are lots of things that I want to talk about here and of course we do not have a lot of time, but I just want to show on the growth chart firstly what we are looking at. So, if we are measuring growth regularly, we can start to see what is happening in terms of her trajectory. So we can see here on her length for age, she is pretty much doing what most kids do in following the trajectory. What she is doing on her weight, is she is jumping across centiles and it would be great to see a measurement done in between here because we might have been able to intervene having noticed that she already experienced some rapid weight gain here in this early period of life. But we obviously have to work with what we have got. But we are going use these growth charts to show mum and dad, mum or dad, or both, whoever is here, we are going to use these growth charts as a visual to show how baby has been growing.
Linda: So one of the responders actually gets the parents to observe the difference. Gives them a copy to go home and have a think, and then bring it back another time. And if you have not got the time to do that, then it seems to me that it would be good to explain that this child…
Linda: You would not use the word fat.
Elizabeth: No, no.
Linda: We would not talk about things in a bad way.
Elizabeth: No, and we know that parents really do not respond well to terms like fat or obese or overweight. Instead we prefer and parents seem to prefer terms like healthy weight, above a healthy weight, well above a healthy weight. But here we would probably say something like, Olivia’s weight is getting ahead of her length.
Linda: So getting away in the race, as it were.
Elizabeth: Yes, as a way of. And here we really try and focus on healthy growth. So we might say that her growth does seem to be accelerating a little faster than we would expect. And here we know that one of the things that we know about Olivia is that we have asked her a few questions about Olivia’s eating habits, and one of the things we find out is that Olivia is a bit of a fussy eater, so is not eating much in the way of solid food, but is consuming a couple of bottles of toddler milk.
Linda: Special stuff.
Elizabeth: Stage 3 formula or toddler milk. So, here is a real opportunity to explain that toddler milks are really cleverly marketed, that they are not necessary, that they are filled with sweeteners and vegetable oils and sodium and have less protein and are expensive. So that might be one of the things that you can talk about to intervene.
Linda: So some of the things that we would talk to Olivia’s mother about would be exactly what Olivia is eating and what she is not eating. And the other thing I would talk to them about is the expectation that we can allow Olivia’s intake to stabilise off and she becomes more active at the age of 15 months, but the chances are that one thing is going to catch up with the other.
Elizabeth: Yes, that is possible, but we cannot just rely on that happening. So it will happen in some babies, that they will when they are active, their weight will come back to a healthy growth trajectory, but we really cannot rely on that.
Linda: So you are saying that we really have to make some more directive suggestions about intake and family eating?
Elizabeth: Yes, exactly. And parents will often say that they have heard that once they are active, they will wear it off but really the evidence suggests that will not happen, that they will in fact continue on that trajectory if we do not start to talk about some of the intake issues.
Linda: Yes, and you have listed some of those.
Elizabeth: Yes. So eating meals together is a really great strategy because you know it is about more than food, it is about modelling and it is about chatting and talking and there are all kinds of opportunities for cognitive development as well.
Linda: And as mentioned in the pamphlet we talked about, the healthy types of food.
Elizabeth: Yes, exactly.
Linda: All of those suggestions are there.
Elizabeth: Yes and they are great things to send mum and dad home with.
Linda: So this is all very nice and you know, GPs do the best we can. Sometimes there is a concern on the part of either the parent or the GP that really treating this difficulty is a problem, and I am wondering, I am having a think about when we would refer them to a dietician or a paediatrician? Again, in the interest of time I am not going to ask the audience but I am going to tell you, when we were preparing this webinar, this came up as sort of a reference and I said, hey you know, the GPs are not going to be sending every child off to a paediatrician because most of just do not have that many paediatric appointments that we can use in this fashion, and at the end of the day, we can actually manage a lot of this. So there needs to be some consideration about when it is appropriate. To me, the kinds of occasions when I would be sending a patient off would be particularly when they are crossing the centiles over a period of time. So how often should I be watching the effect of my advice with measurements?
Elizabeth: Well I think with Olivia, you would be asking her to come back in a month and you certainly if she came in earlier than that you would be asking, you would definitely be weighing and measuring her again.
Linda: So how many of those months do I have to watch until the trend is enough for me to act if I am concerned?
Elizabeth: Yes, I would think that a couple of months.
Linda: So maybe two more measurements and we can see if it is levelling out, in which case my advice is helpful, or it is not. And of course, if there is any other clinical indicator that I have concerns about that would suggest some other medical condition, needless to say, that is a reason for going off that. But maybe I should use a dietician?
Elizabeth: Exactly. I was just going to suggest that. I think using a dietician is a really good idea. And another thing to just think about is yes, is whether you know, we know that it is often the case that mum and dad might be above a healthy weight as well, so one of the things you can think about is referring to the Get Healthy coaching service. So that is a free service. It has been really effective.
Linda: So that is in New South Wales.
Elizabeth: Yes, New South Wales is a key service. It is in South Australia as well. And it has been really effective in terms of adult weight management. But because we are going to be looking at a whole family approach here, we are not going to isolate this one child, then that can be a really great way of helping parents to lose weight themselves and to become healthier for all their family.
Linda: And what we are finding of course is that to use your local pathways resource.
So the practice points we have mentioned to you are measuring the weight and length regularly to inform your assessment. Using growth charts to plot. I know I use the software because it is easiest for me. Serial measurements are what matter. Of course if the infant is crossing centiles, that is where you start the conversation. We all know that brief interventions from general practice is actually quite useful because we can do it over and over again. And we have resources that we can refer people to.
There is a list of resources that are here and some of them I will recommend to you because they are past webinars including our own Professor Elizabeth Denney-Wilson, which includes the ways of actually having these conversations, and looking at ways of using Medicare to support the treatment for childhood obesity. Information too, about healthy kids interventions and again more resources about the conversations that come as webinars which are available through the RACGP. Similarly we have mentioned to you some “how to” stuff, how to teach your baby to drink from a cup and the guidelines we talked about before.
So racing to the end of this webinar, sorry about the rush guys, you should be able to be aware of infant feeding behaviours associated with rapid weight gain and childhood obesity in infancy, assess growth in zero to two-year-olds and identify rapid weight gain, using weight for length charts. Be aware of current guidelines and recommendations for infant feeding. Provide advice to parents about best practice formula feeding, including how to feed, the difference between formulas and what to look for when choosing a formula, and the ability to discuss infant growth with families and use available resources to provide advice to families about infant feeding. Thank you, Elizabeth.
Elizabeth: Thank you very much, Linda.
Beth: I would like to take a moment to thank our presenters once more for joining us this evening. I would also like to thank everyone online. We hope you enjoyed the session, and enjoy the rest of you evening.