Tackling childhood obesity - part 3

Sammi: Good evening everybody and welcome to this evening’s having conversations about healthy growth in young children webinar. My name is Samantha and I am your host for this evening. Before we kick off, 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 and we pay our respects to Elders past and present.

Okay, so I would like to introduce our presenters for this evening. We are joined by Professor Elizabeth Denney-Wilson. 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 complete a trial of an App to support healthy infant feeding and promote healthy rather than excessive weight gain and growth. She is part of the Early Prevention of Childhood Obesity Collaboration and a team that has been awarded an NHMARC grant to roll out a child obesity prevention intervention across Victoria.

We are also joined tonight by Professor Mark Harris. Mark is Executive Director of the Centre for Primary Healthcare and Equity at UNSW. His main research interests are in the prevention and management of long term illness in primary health care and health equity. His clinical work is as volunteer with the Sydney Asylum Seeker Centre. So, thank you Elizabeth and Mark for joining us this evening.

Elizabeth: Thank you.

Sammi: I will hand over to Mark now to kick off our presentation this evening.

Mark: Okay. Thank you very much. So, we are going to start with this question, which is really to help you to think about whether excess weight gain is an issue for nought to two year olds in your practice and to reflect on how often you talk to families about unhealthy weight gain in this age group.

The learning outcomes are on the screen now. By the end of this online activity, you should be able to assess healthy weight in nought to two year olds and identify rapid weight gain using weight for length charts. To be aware of the association between rapid weight gain in infancy and obesity in childhood. Be aware of current guidelines of recommendations for the introduction of solids, movement and screen time in infants. Provide advice to parents about best practice formula feeding including choice of formula and ways of identifying hunger and satiety cues. Lastly, to discuss infant’s growth and provide advice to families about introducing solids, appropriate foods and portion sizes. So now I will hand over to Elizabeth, who will begin the presentation.

Elizabeth: Thanks Mark. So perhaps you will already be aware, in New South Wales we have a Premier’s Priority to reduce childhood obesity by 5% by the year 2025. Now in order to do this, New South Wales Health has placed significant investment into a large range of programs in the community, in schools, in childcare centres, social marketing campaigns, to start really educating people and creating a healthy environment to enable better choices. But as part of this priority, New South Wales Health has a Routine Advice and Clinical Engagement Strategy, which is about improving the way we as a whole health system, manage and prevent childhood obesity. And as part of this work, New South Wales Health have funded this webinar and a series of webinars and that is to help support practice. So this area of work is currently focussed on embedding prevention and management of childhood obesity as part of routine clinical care.

Now in New South Wales, about 22% of children are above a healthy weight. This comes from New South Wales Population Health surveys and the prevalence of childhood overweight and obesity has been relatively stable since 2007. Overweights are still high and there is some socioeconomic disparities that mean that in some parts of the State, many more children are above a healthy weight. The persistence of excess weight once established is a cause for concern. There are two high risk periods for gaining weight, one in the nought to three year age group and one in the young adult age group. And by about three years of age, 20% of children are already above a healthy weight, making early childhood a critical intervention period. The first two years of life have become a key target for prevention and coincidentally, is a time when infants and their parents are frequent visitors to general practice.

Mark: So, in Australia out of every 200 children presenting in general practice, 60 are above a healthy weight or well above a healthy weight. There is actually 23 who are well above and I can see that from this diagram. But only one is offered weight management interventions, so clearly there is room for improvement.

Elizabeth: So one of the tools that exist to assist clinicians in primary health care, is the Healthy Kids for Professionals web page. And this has been developed to support assessment and management of children who are above a healthy weight. The web page has been designed to support all health professionals and especially general practitioners, to undertake routine growth assessments of children, and a range of resources including weight for age charts, BMI for age charts, fact sheets and a weight status calculators as well as online learning modules and videos can be accessed on this site. This site is free and available to people across Australia.

The website has some really useful posters too that can be downloaded and printed. And one of them is this great one that might be really useful for your practice. And one of the great things about this is that it reminds us that young infants, so infants from nought to two, should be measured supine. In Australia, the consensus is that for nought to two year olds, the World Health Organisation growth charts are recommended as the standard for clinical evaluation of growth. These charts have been developed based on longitudinal data from healthy children in six different countries. They are available in Medical Director and in Best Practice but can also be downloaded from the Healthy Kids for Professionals site if you are not using one of those software programs. From the age of two, the Australian consensus is that the Centre for Disease Control Charts should be used and they are also available on the Healthy Kids for Professionals site.

You will also find the World Health Organisation Growth Chart in the Blue Book, also called the Green Book and different coloured books of course in different states. Sorry for being so New South Wales centric. So, on your screen now is your sort of common garden variety weight for age chart. What we know is that one off measurements do not give sufficient information to give an assessment about growth. Tracking of growth over time is most important because most babies will sit on a centile and they will stay on that centile all the way up to even up to age 18. I measured my kids every six months until they were 18, but they did not sort of like it much by the time they were about 13, but I could see that they were both tracking centiles and so I knew pretty early that neither of them were going to play rugby for Australia. Some kids however do not track growth centiles and they have what is called rapid weight gain and this is where they cross growth centiles. Now rapid weight gain is defined as an increase in standard deviation of 0.67 and that roughly corresponds to a centile line. Sometimes this is catch up growth because they were born prematurely. But a more frequent occurrence in this day and age is that babies for one reason or another are growing too rapidly.

We have recently conducted some research with child and family health nurses, and one of the things they find is that some parents think that a child jumping centiles is actually a good thing and to be celebrated. So parents may need support in understanding that there is nothing inherently better about the 50^th centile versus the 80^th centile. So long as a child is growing it does not matter which centile they are on and so much of which centile they sit on is determined by their parents and their genes.

So, research to develop and trial interventions in the first two years of life has been relatively limited, but in a comprehensive systematic review, including studies examining all possible modifiable risk factors for childhood obesity, all the way from the antenatal period to the first two years of life, rapid weight gain was found to be one of the most consistent risk factors for overweight or obesity in later childhood, with 45 of the 46 included studies finding positive association.

Mark: So what can be done?

Elizabeth: Yes, thanks Mark. So one of the things we know is that rapid weight gain is more common in infants fed with infant formula than those who are breast fed. So one of the first things that we can do it to really encourage and promote breast feeding. But I guess many of you in general practice would be seeing people who have already stopped breast feeding. So, in that case there are some things that we can talk about. Rapid weight gain is more common in children who are bottle fed and fed to a schedule rather than fed according to their hunger and their satiety. It is also more common in children who have early introduction of solids, so before four months. And it is more common in babies who are fed to settle. So this would include babies who are given a bottle to go to bed and are able to continue drinking that bottle even after they have dozed off to sleep. There is also a bit of misinformation around that when children start to move, that that might actually resolve the issue. And that really does not tend to happen.

Mark: There is a question here about, at what stage would you expect a healthy catch-up weight to occur for a baby born small for gestational age or a premature baby?

Elizabeth: Yes, you would expect that to be pretty well done, the baby would have settled onto a centile by about four to six months. So you would be hoping they would be relatively stable after that. But thanks for that question.

So, when we are assessing growth one of the things I mentioned earlier is that it is really important to take several measures of growth in order to determine how a baby is tracking. And so we recommend and certainly the Australian Infant Feeding Guidelines recommend that babies are measured at every visit. But if you do determine that a baby is experiencing rapid weight gain, then there is really, there are quite a few other things that we should be talking about with parents. One of them is their feeding practices, so whether they are breast feeding or formula feeding, whether they have introduced solids and if they have, what kinds of solid foods have they introduced and what is the quantity of that solid food. And are the babies having drinks other than water or milk. Now we know that babies do not need any other fluids other than milk, breast milk or infant formula for that first 12 months of life, so that is really important that we are not introducing fruit juice or any other teas or sweet milks or any of that sort of thing which is common in some cultures. We would also be asking about sleep because the association between sleep and rapid weight gain is quite mixed. Some studies have shown a negative association between sleep duration and rapid weight gain, but others have not. But we do know that interventions that teach parents to settle, settling strategies other than feeding to sleep, have been effective in reducing infant weight gain. In terms of physical activity, obviously little infants are not particularly active yet, but things that you can do to increase physical activity and indeed encourage the development of skills for physical activity including popping the baby on their tummy, so having tummy time, having active play, like encouraging babies to reach for toys and to grasp and having time lying on their back kicking without a nappy. But most importantly to not be restrained in a child seat and to not have screen time.

There are other issues at play here, and one of them is the influence of grandparents and we often talk about the influence of grandparents from some cultural backgrounds who are delighted to have a child who appears to be above a healthy weight. So that is a real challenge, addressing some of those cultural norms about appropriate size of babies and appropriate weight gain. So lots of other things to consider.

So the mechanism is not completely understood, but breast feeding has been shown in some studies to be protective against later obesity and it certainly is very uncommon for breast fed babies to experience rapid weight gain. So breast fed babies often grow at a slightly different weight than formula fed babies, and indeed formula fed babies are heavier at 12 months than breast fed babies. Some parents want to top up breast milk, fearing that their baby is not growing fast enough, but so long as the baby has regular increases in weight, in length and in head circumference, and has about six wet nappies in a 24 hour period, then we know that they are indeed getting enough to drink.

Mark: Okay. So we are going to look at a case. So, Jack and his mum, Sasha present for a six week immunisation and health check. Jack is Sasha’s second child and she did not breast feed her first child. Sasha is concerned. She feels her breast milk supply has dropped as Jack’s sucking time at the breast has decreased and he comes on and off a breast during a feed or throughout a feed. Jack has a few short feeds between 4 pm and 6 pm and feeds twice overnight any time between 11 pm and 6 am. Jack was born at term and his birth weight was 3.5 kg which was on about the 50^th percentile, and six week bear weight was 5.2 kg. So he has put on 500 grams in two weeks. Six week head circumference was 39 cm which again is on the 50^th percentile. His length, 54 cm which was just under the 50^th percentile. So, Sasha asks should she be giving Jack formula as well as breast feeding? What do you think?

Elizabeth: Well I think the first thing to say to Sasha is what a great job she is doing with her parenting and indeed with her breast feeding, because Jack has actually put on more weight in the last two weeks than you would expect a breast fed baby to gain. So, she should be very comforted that Jack is doing exactly what breast fed babies do, and that is regulating his own appetite and as a breast fed baby, he is able to feed according to his hunger and he is able to stop feeding according to his satiety which is something that formula fed babies may not be able to do. So, I would be encouraging Sasha to keep going with her breast feeding and that no, Jack definitely does not need to be topped up with formula.

Mark: If she was still anxious, is there anywhere she can get help?

Elizabeth: Yes, absolutely. So, Sasha can get help from a group like The Australian Breastfeeding Association who have a 24 hour help line and have regular local meetings and she can also of course see her child and family health nurse who are specialists in child feeding.

Mark: Okay. And now, formula feeding.

Elizabeth: Yes. And so formula fed babies are heavier at 12 months on average than breast fed infants and there are a few possible mechanisms and one of them is that formula fed babies are not necessarily able to adjust their intake according to satiety. So, when I first became interested in infant feeding, so this was when my now adult children were babies, one of the things we really worried about was parents diluting infant formulas to make it last longer. But now the opposite is actually true, where we know that some parents put a bit of extra formula in the bottle because they have heard it might help a baby to sleep better or because they are worried that the baby is not gaining enough weight. But more recently, the protein content of infant formula has come under investigation and we know that babies fed a low protein formula are less likely to experience rapid weight gain, and this again could be quite confusing for parents. So parents could be forgiven for thinking that since protein is something they have almost certainly heard of, and they have almost certainly heard of as an important nutrient, that if they were comparing infant formulas, they might chose a high formula, high protein formula rather than a low protein formula.

Another piece of research that has recently been completed by one of my students. She found that mums mostly get their information on formula feeding from the side of the tin and so it is important that they actually use the information on the tin and they use the scoop provided because the scoops in different formulas can be of different size and it is also important that they use level scoops rather than rounded scoops. So there is a few things that we can do to support parents who are formula feeding.

Mark: So there are a couple of questions that relate to that. One is, is rapid weight gain in a bottle fed baby at six months really that much of a problem?

Elizabeth: Well, what we know is that at six months, a baby who is experiencing rapid weight gain and who continues to experience rapid weight gain, is somewhere between three and six times more likely to be overweight or obese, or above a healthy weight when they are children and when they are adolescent. So it is the most persistent risk factor for childhood obesity that we know to date. So, it certainly deserves watching carefully and it deserves looking really closely at, at the ongoing growth of that baby.

So one of the really important things about formula feeding that a lot of parents do not necessarily follow is that because the side of the tin tells them how much volume of formula to make up, once they have made up that amount of formula, they tend to keep feeding that until the bottle is empty, and this can override an infant’s hunger and satiety cues and may lead to excess weight gain. So I have watched a lot of mums and I am sure you have too, jig a baby up and down and persist with the feed even when the baby has clearly had enough and is showing signs of fullness. So they might have stopped sucking. They might have turned their head away. They might have even fallen asleep. So one of the things we can do, is to help parents to read and understand their baby’s hunger and satiety cues. And this could be a potential preventative strategy, especially if rapid weight gain is already present.

Mark: There is a question that I do not understand I am afraid, Elizabeth, which is what about paced bottle feeding? What does that mean, I do not know.

Elizabeth: Paced bottle feeding. Yes, I am not really sure but I know that there has been some work done in the United States about providing bottles that are opaque so that parents are perhaps more likely to use the cues of their child rather than the bottle emptying. There has also been some work done with different sized teats so that the high flow teats are not as good as the low flow teats, so the baby has to work a bit harder to get the milk. I am not really sure if that answers the question, but…

Mark: And another question about expressed breast milk by bottle.

Elizabeth: Yes, yes.

Mark: Obviously there is not the issue around mixing it up, but maybe are there still issues around knowing when a child is full?

Elizabeth: There absolutely is. So, babies fed with expressed breast milk with a bottle are more likely to experience rapid weight gain than breast fed babies fed in the usual fashion, but obviously there are not the issues with protein content, but there are still the issues with hunger and satiety and the use of bottles.

Mark: Okay. So that is a question about when should solids be introduced? So most people are answering between four to six months and another group, at six months. So thank you.

Alright so we will move onto the next.

Elizabeth: So that is really interesting and indeed the majority of our participants are right because it is a bit of a trick question. So, the Australian infant feeding guidelines state that when your infant is ready at around six months, but not before four months is when solids should be introduced. And some of you might be interested in babies who are at risk of allergies, and so last year there was actually an Australian infant feeding summit and this was convened to address the confusion over the introduction of solids for infants at risk of allergy. So the consensus statement agrees with the Australian Infant Feeding Guidelines, so that is that at around six months and not before four months is when a baby should be introduced to solids. Now this is obviously if a baby is ready. So, the signs that a baby is ready is that they have good head and neck control, they can sit upright when supported and they show an interest in food. For example, they might be looking at what is on your plate. They might be reaching out for your food or opening their mouth when they are offered food on a spoon. Most babies start to show these signs around six months, but obviously the signs happen at different times for different babies.

So when thinking about the schedule of starting solids, so from nought to six months, we are recommending breast milk or formula only and then from six to twelve months, breast feeding or feeding of infant formula would continue but starting to introduce a variety of solid foods. First foods should be iron rich foods, and this is a bit of a change from what a lot of grandparents would have heard should be the first foods. So, iron fortified cereal or mashed meat, fish, chicken or legumes are the recommended first foods. And this is also a good time to start offering cooled boiled water in a cup rather than in a bottle. It is important to keep offering a variety of healthy foods and also to again be mindful of a child’s hunger and satiety cues.

Mark: Does it need to be pureed, or mashed?

Elizabeth: Yes, so you need to start with really sort of finely mashed, and often using one of those stick blenders is a good thing to do. But again the Healthy Kids for Professionals site has some great resources that can be downloaded and passed on to families to help them with introducing solid foods. Importantly too from 12 months, cows’ milk can be introduced and this is a really important issue because lots of families have been, have seen advertisements for toddler or follow on formulas and these are really unnecessary if a baby is eating a healthy family meal based diet.

So there is some key preventative advice we can offer to families. So, at six months we would be starting with just one to two teaspoons of solid food. By seven months, we would be slowly increasing to three meals a day and by nine months we would be offering a maximum amount of one cup at each meal. So one of the key mantras that we like to suggest is that parents provide and child decides. So the parent is acknowledged as really the key gate keeper in terms of what kinds of foods are offered to the child and what the food environment that the child grows up in is like. And it also acknowledges the child’s capacity to know when they are hungry or when they are full. We really do not need to offer fruit juice or sugar sweetened drinks or add salt of sugar or other flavourings to meals in this age group, or indeed ever, really.

Another piece of key preventative advice that we can offer is the amount of active play. So, supervised tummy time for around 10-15 minutes three times a day is recommended in terms of the guidelines for healthy growth and development. Too much screen time can have an impact on children’s language development and social skills and this is because children need real life interaction to develop these skills. The guidelines suggest that children under 18 months should avoid screen time other than video chatting, and that children aged 18 months can watch or use high quality programs or Apps if the adult watches or plays with them to help them understand what they are seeing. There is absolutely no evidence that Baby Einstein or other videos designed to improve babies’ brains actually have any effect. But we acknowledge that these guidelines can be a challenge for some families and that it can sometimes be a difficult issue to raise limiting screen time.

Mark: So, let’s look at a case study. So, Thomas is a 12 month old child who presents with his mother with a suspected ear infection. He was exclusively breast fed for three months and then had formula. He has recently moved to a toddler formula. Thomas started solids at about five months. His mother said he can be fussy when tired but enjoys most family foods. And these are his growth charts, his weight for age and length for age charts. So after plotting Thomas’s growth you are concerned about his weight, that it is tracking more quickly than expected. So what other information would you need before giving advice to Thomas’s mother?

 

Elizabeth: So are we getting any thoughts from our audience?

Sammi: Yes. Someone has asked what is his diet?

Elizabeth: Yes, really good question. We definitely need to ask about the volume of solid food, the type of food, how often Thomas is eating. Sometimes hungry children, or sometimes children are provided with much bigger portions than they need at this age.

Mark: We are also getting suggestions about fluid intake, especially of sugary drinks.

Elizabeth: Absolutely, yes. Yes. Those are all really good questions. So I guess

Mark: How active is he? Is he walking? What are his daily activities? Screen time? Why is he on formula?

Elizabeth: Yes, absolutely. The toddler formula is a really good question and something that you could definitely raise with mum. So, perhaps one of the things to start the conversation might, we might talk to the mum and say that, explain that it is difficult tell whether a child is growing in a healthy way just by looking at them. So it would be important to measure their length and weight regularly to help monitor their growth. One way of raising the issue is to say I have plotted how Thomas is growing on this chard and we expect most children to follow one of these percentile lines as you can see Thomas’s weight has moved above the centile line he started on. You can ask mum if she has seen Thomas’s growth plotted like this before and what she thinks of it.

Mark: So if she asks, isn’t it just puppy fat?

Elizabeth: So, one of the things we could talk to her about is that what we now know is that most children who are above a healthy weight will continue to be above a healthy weight. Indeed about 80% of children who are above a healthy weight will go on to become adults who are above a healthy weight. So the important thing for Thomas is that we set him up with healthy lifestyle habits for life. So Thomas is probably fairly good at knowing when he is full so it important to provide Thomas with healthy foods and allow him to choose how much he will eat. So.

Mark: There are some comments here about whether we should be checking the child’s sugar levels in the blood?

Elizabeth: I would think that we could continue to monitor his growth first. I guess if there is a family history or what would you do Mark, if there was a family history of?

Mark: I guess what the concern is, is whether the child has got type 1 diabetes, but it is unlikely to manifest in this way I guess. And the, yes, so I think that that is unlikely to be the problem in my experience. There is another question about the benefit of toddler formula and whether that increases, whether we need that in terms of things like iron and vitamin D?

Elizabeth: No. If Thomas is having iron rich foods as part of his diet then he really should not need those fortified formulas. He could have some cow’s milk.

Mark: What about a vegan household?

Elizabeth: A vegan household?

Mark: Or vegetarian household.

Elizabeth: Oh, would he still be drinking regular cow’s milk and having legumes and other iron, other non-meat sources of iron? Yes.

Mark: Yes, I guess so. So I guess that is something to ask about, isn’t it, the details of his diet and whether he is getting sufficient iron and milk. I guess with a vegan diet it is a bit more challenging.

Elizabeth: It would be more challenging, but again it is the kind of thing that it would be really useful. If parents following a vegan diet, it would be a really good thing to actually chat to a dietician and really get some really expert advice in terms of Thomas’s intake. But I think just based on this, on what we know so far about Thomas, I think the thing to do initially is to ask some questions about his quantity of solid food and how much of the toddler formula he is drinking and look at his activity and sleep.

Mark: Okay, so this is the next question, which is what are one to two healthy behaviours that you could suggest for Thomas?

Elizabeth: So I think we have already received a few suggestions from our participants. So definitely one of them was about the toddler formula and whether we could look at that, and we also had a comment about physical activities. So whether Thomas is crawling or walking. So one thing might be to talk about screen time and think about whether that is something we could limit. Also encouraging active play, so again there are some really nice suggestions for encouraging active play that families can, that GPs can find on the Healthy Kids for Professionals website. Other things to think about is to think about avoiding juice and flavoured milk and sugar sweetened drinks, to choose healthy snacks like yogurt, vegetables and fruit and to add vegetables to meals. So, really having a good look at the diet would be really useful. Another thing I would add, is whether Thomas is going to bed with a bottle, because that is a very common extra source of calories for a baby who continues to suck even though they are fast asleep and is having as much as 100 ml of extra calories they do not really need. And maybe to also ask about whether Thomas is still having feeds overnight and they could perhaps be discontinued.

Mark: Can you comment about kids becoming milk addicts?

Elizabeth: Yes. Yes, I had a milkoholic. Well he would have been had he not had me as a mother. But still a bit of a milkoholic as an adult. It certainly seems to be quite common and it particularly seems to be something that is experienced in some cultural backgrounds, particularly where milk might not have been a regular part of the diet that now that it is readily available in Australia, some grandparents we hear from child and family health nurses, that some grandparents really push milk because it is available and they know that it is a really nutritious food. So once we get to about 12 months it is really important that we transition to family foods and that the child participates in family meals. Not just because of the nutrients but also because of all of the socialising and all of the other things that come with eating family meals and that milk is offered as an adjunct to that rather than as the first choice of food.

Mark: There is another question about if you have three kids and only one is overweight, how would you, would that relate, what would you be looking for there?

Elizabeth: Yes, so again this is something that we do get asked about quite a lot and the really important thing is, that with all of the pieces of advice and suggestions that we might offer to a family that they really are the kinds of things that a whole family can adopt, and that is what we would be encouraging. So all of the things that we suggest and these include things for older children like choosing water as a drink, being active as a family, avoiding juice and sugar sweetened drinks, getting a good night’s sleep, limiting screen time. They are things that will do no harm to a family and will actually benefit the whole family including the adults in the family. So isolating or singling out a child who is above a healthy weight is not something that we would suggest or something that we would encourage. Rather we would encourage whole of family approaches to healthy eating and physical activity.

Mark: Okay. So.

Elizabeth: So, if we think about engaging with Thomas and his family, we really need to keep reminding families about why this is important and supporting them to start a new habit. And so we might ask Thomas and his mum to come back in a few weeks’ time to review Thomas’s growth. We might also suggest that they pick one or two new habits to try first and one of them might be cutting down on the toddler formula or replacing it with milk. Or another habit might be to encourage more active play. So rather than bombarding a family with five new habits to change, we might help them by suggesting one at each visit.

Of course if Thomas comes back to the practice for some other reason, that would be a really nice opportunity to weigh and measure Thomas again. But if we think about providing just a brief mention, a brief intervention at every visit, it is not unlike we might reinforce a message about using an asthma preventer. We would not just tell them once and stop. We also need to remember though that this can be a slightly contentious topic for some families and so we need to be careful to roll with resistance and to not badger families but rather to let them know that we are there. We are there to provide them with support and encouragement and to provide them with advice when they are ready to change their behaviour or to adopt a new behaviour.

Mark: So these are some practice points that summarise some of the key messages we have talked about. To measure weight and length regularly. It is really important to have a series of assessments so we can really look whether a child is crossing centiles or not. And to plot on the growth chart and make those serial measurements. If the infant crosses the centiles, then asking about feeding practices particularly but also sleep and movement and screen time. On providing brief interventions. You know even though often we might have concerns about raising it with families, especially if there is sort of anxiety or guilt. Sometimes mothers feel guilty about introducing formula because of you know not continuing with breast feeding. It is important that parents expect that a GP will talk to them about this and give them some advice and refer them if they are concerned. And lastly, consider referral, particularly to a child and family nurse or a paediatrician.

So, we might just, we have got some resources to talk about, but before we do that we might just flip back and have a look at some of the other questions that we have jumped over. One recent one was about can we calculate BMI under the age of two? So it is recommended that we use BMI for age charts in children over two, that is the healthy weight BMI charts. But can we use that under two?

Elizabeth: Yes, the Australian consensus is that we do not use BMI for age under two, that we do start using it in the over two year olds, because the feeling was that there is insufficient evidence of the association between a high BMI in the under two year olds and being above a healthy weight later in life. So the suggestion is not to.

Mark: Another question. If height and weight are both above the 97^th percentile, is this acceptable? Elizabeth is looking at me now.

Elizabeth: I am doing no such thing. I think the really important thing about growth charts is that they are a tool. They are something but you would be using your clinical judgement. So if mum and dad have both come in and mum and dad are both tall people who, tall and of a large frame, then we would be less concerned than if mum and dad were slight tiny people with a baby over the 97^th centile.

Mark: It also depends on you know, if the height is just over the 97^th percentile but the weight is well over, you might be more concerned.

Elizabeth: Absolutely. And look I think the general consensus too that above the 97^th centile or below the third centile it probably is appropriate to look a little deeper because those are the extremes. But again, using your clinical judgement and using growth charts as a tool rather than a diagnostic instrument I think are the key messages.

Mark: We have an explanation of what paced bottle feeding means.

Elizabeth: Oh, thank you.

Mark: Which is using a slow flow teat and folding the bottle quite flat and tipping forward slowly and giving the baby breaks and so on. So what about that?

Elizabeth: Well I think so long as we pay attention to a baby’s hunger cues and their satiety cues and feed, do not feed according to a schedule, but feed according to a baby’s hunger and be sure that parents understand that baby is hungry and full at different times on different days and that feeding every four hours might not be realistic for most babies. Especially in those early couple of months they might want to feed a lot more frequently. And they might want to feed a lot more frequently when they are having a period of rapid growth.

Mark: There is a question about why do babies need boiled water in Australia?

Elizabeth: That is a really good question.

Mark: Okay. And then there is a number of questions about introducing solids and there is the one question, doesn’t the ASCIA say four to six months?

Elizabeth: So this is the allergy group? Yes so there was, because that was causing confusion last year there was an Australian infant feeding summit and that was a summit organised by the group who are particularly interested in children who at risk of allergies, and at that summit the consensus statement was that solids be introduced at around six months consistent with the Australian Infant Feeding Guidelines. But they do suggest that babies be introduced to potentially allergenic foods like peanut butter, eggs et cetera in that second six months of life, so in the first year of life.

Mark: So there was actually a question about eggs. When can we introduce eggs? So we talked about iron rich foods. Are eggs included in that?

Elizabeth: So long as iron rich foods are the first foods, so again things like mashed meat and fortified cereals, legumes that sort of thing, it does not really matter what the next foods are. So you can introduce vegetables after that or a little bit of egg.

Mark: Or cheese.

Elizabeth: Or yogurts. Those sorts of things are fine to come next. Vegetables. But again, the iron rich foods are really the important thing because iron and zinc stores are starting to deplete.

Mark: And not pureed fruit.

Elizabeth: No, not apple sauce or, no please, no.

Mark: That was certainly the norm. There is even a variety that has sort of a picture of grandma on the front I think. And anyway.

Elizabeth: Yes, I have not had to go down that isle of the supermarket for quite a few years now, but I am hoping to have to go down that isle again in the next ten years.

Mark: There is a comment about puppy fat which I thought was good. It is saying, he is not actually a puppy.

Elizabeth: No that is a really good point and I actually have a slide that I use in some of my presentations that is a picture of a rather above a healthy weight puppy and I do indicate that it is not good even for puppies.

Mark: Sorry I am just looking for some other questions. Yes. Are parents’ weight and height reflected in the child’s height and weight during infancy?

Elizabeth: Yes, they can be. So, it is again important to use the growth chart as a tool and to have a look at mum and dad and see what kind of height and size that they might be. I guess one other thing that might be of interest is that in terms of infant weight, there is some evidence that intervening in the antenatal period, so during pregnancy, that interventions in that period to help women who are above a healthy weight to not gain too much weight, can have an effect on infant birth weight. But there is really insufficient evidence yet to see whether that has an effect on babies throughout the first year of life.

Mark: There is a question about how often to measure height and weight. So we have said regularly. Is that sort of three monthly, or two monthly?

Elizabeth: Well, I think because babies are seen in general practice pretty regularly, I think the average is about six visits in the first year of life.

Mark: Something like that.

Elizabeth: I think saying every visit is reasonably safe. I mean, I guess if you were seeing a child three times in one week to follow up on a particular condition, you would not need to do it. But if a baby was coming in once a month or once every couple of months, it would certainly be appropriate to measure at every visit.

Mark: But probably not much value in measuring less than once a month. More frequently.

Elizabeth: No. And when you are thinking about supporting parents who might be concerned that a child is not gaining enough weight, we do suggest that we look at an average over four weeks. So, if you were concerned about a child’s growth it would indeed be appropriate to ask them to come back in four weeks and to have a bit of a look at their weight gain over that period of time.

Mark: So we have got some webinars that may be of interest. Here are the links to those webinars. One on tackling childhood obesity in the context of different socioeconomic and culturally diverse backgrounds. Healthy Kids for Professionals: Managing children above a healthy weight. Healthy Kids for Professionals: Raising the issue by Dr Georgia Rigus and Dr Shirley Alexander. And the one on Lifestyle intervention and Go4Fun referral. So those resources are available through the College website. And please feel free to go to those if you have not done so already, and some of those are mentioned during the presentation.

There is also some important resources. The Personal Health Record. Starting Family Foods. Healthy Beginnings parenting booklets. Raising Children Network. The 24 Hour Movement Guidelines. Infant Feeding Guidelines and the Australian Breastfeeding Association also is another source of information. And Tresillian and Karitane. And of course there is the Healthy Kids website.

Elizabeth: Yes, I would really encourage you to use the resources on the Healthy Kids for Professionals website. They are really fabulous and they are age appropriate and great resources to download or to order and have in your practice.

Mark: So to recap on the learning outcomes for this session in the last couple of minutes. So assessing healthy weight gain in zero to two year olds. We have talked about that and particularly the importance of identifying rapid weight gain when there is children who cross the centiles. Being aware of the association between rapid weight gain in infancy and obesity later on. We have talked about that. And the current guidelines and recommendations for introducing solids. So, around six months and also, the guidelines around encouraging movement and not exposing children to screen time under the age of two. Providing advice to parents about best practice formula feeding, including choice of formula and the way to identify hunger and satiety cues. So we have talked about the importance of following the instructions and the importance of not over-feeding children, providing the child with the opportunity to eat but not forcing them and not pushing the food on them. And discussing infant growth and providing advice to families. And this is what families want and expect and it is obviously a sensitive topic but it is something that if handled sensitively can really be very helpful for parents.

Sammi: Wonderful. I would like to thank Mark and Elizabeth for joining us tonight and for delivering this presentation. I hope that everybody online found it really useful and that you are now better and more confident in those learning outcomes that Mark just recapped with you. So thank you Elizabeth and Mark, and thank you to everybody online as well. We hope you enjoy the rest of your evening.