Think about health promotion opportunities in your clinical practice related to gastrointestinal problems, bearing in mind the following:

• The period between conception through to a child’s second birthday is considered to be the most crucial from both a developmental and a nutritional point of view.

Infant nutrition

• Breast milk contains all the nutrition an infant needs and current guidelines from the World Health Organisation recommend exclusive breastfeeding for the first 6 months, followed by continued breastfeeding alongside solids until 2 years of age or beyond.
• When breastfeeding is not possible due to infant or maternal ill health, or maternal choice, infant formula can be used as an alternative. Where infants have been unwell, the choice of formula may be dictated by their gastrointestinal capability, alongside dietician advice.
• In order to achieve optimal growth, the newborn infant has high calorie and fluid requirements, needing 150mls/kg per day of fluid and 110kcal/kg of calories. Breastmilk contains colostrum, a thin yellow-coloured milk produced in the first few days following birth, which is high in immunoglobulins, but breast milk is low in vitamin K, so it is standard practice to give vitamin K at birth to aid blood clotting.
• It is difficult to measure breastfeed volume, so mothers are advised to feed until their baby appears satisfied and content. A breastfed infant should feed around 8 times a day and have at least 6 wet nappies and 2 soiled nappies each day.
• Formula fed infants should be fed at 150mls/kg a day with milk formula made according to the manufacturer’s instructions. This is important to ensure the infant is receiving the correct calorie, fluid and nutritional amounts. Formula feed strength should not be altered unless it is done so under dietician advice and supervision. Formula fed infants tend to feed less often than breastfed, but should still have the same volume of wet nappies each day. Feeds should not be made up with bottled water – this may contain too much sodium and is not sterile.
• Around 50% of energy in the infant diet comes from fat.
• Cow’s milk is not recommended under the age of 12 months.

Weaning

• Current advice is to start weaning at 6 months of age. Before this, the infant’s digestive system may be too immature to manage solid food. Signs an infant is ready for weaning include:

• Has head control and can stay in a sitting position
• Can co-ordinate eyes, hand and mouth
• Can swallow food – an infant who is not ready will push food out of their mouth

• First weaning foods should be smooth and easily digestible such as puréed vegetables, fruit or baby rice. The infant should be encouraged to handle their food and to feed themselves as soon as they show an interest.
• Weaning is a risk point for choking, so the infant should not be left alone when eating.
• Once an infant is showing signs of interest in handling food (around 7–9 months), they can have finger foods (small pieces of food, which the infant can hold and chew on) and from here, they can progress to semi-puréed (mashed) foods containing small lumps.

Toddlers and pre-school

• Toddlers and pre-schoolers continue to have a high energy requirement due to their continued rapid growth and increasing activity. They should now be able to eat the same types of foods as adults, although they will still require their food to be cut up small and have smaller portions. The pre-school child should be gaining around 35% of their total energy from fat in their diet.
• A balanced diet in this age group and beyond should include a mixture of:

• Bread, cereals, grains, potatoes, pasta and rice – these foods provide energy, fibre, vitamins and minerals
• Fruit and vegetables – these are a source of antioxidants, vitamins, minerals and fibre
• Meat, fish, poultry, eggs (or vegetarian alternatives) and pulses – these foods provide protein, iron, vitamins and other minerals
• Milk and dairy – important for healthy bones and teeth as they are high in calcium, as well as providing further vitamins and minerals.

• Sugary food and drinks should be kept to a minimum to reduce dental caries.
• Whole fat milk is recommended until the age of 5 years.
• The diet should be balanced, with a high vitamin and mineral content. Iron deficiency anaemia is common, especially in ‘picky eaters’, as is constipation, which may benefit from an increase in dietary fibre and fluid intake. Of particular importance in this age group is a good supply of protein, calcium, iron and vitamins A and D, which are important for growth, bone development and immunity.
• Children who consume a high number of sugary drinks and fruit juice may experience ‘toddler diarrhoea’.
• Obesity is less common in this age group, but is steadily increasing. A healthy family approach to food with the opportunity for physical exercise is important in avoiding weight gain.

Nutrition in school-aged children

• During this stage, children are still growing and remain relatively active, so they continue to have high energy requirements. As the child grows older however, high fat foods should be reduced and dietary fibre increased to be more consistent with an adult diet. In recent years, increasing numbers of school-aged children have been noted to be overweight, with some school children being classed as obese. Consequently, promoting a healthy diet and healthy weight amongst the school age population has become a major public health concern.
• Children should have their height and weight measured in reception class and again in year 6 as part of the National Child Measurement Programme. Parents of overweight children should receive information and support, alongside referral to an appropriate weight management service, in order to enable the child to move towards maintaining healthier weight and lifestyle.
• The majority of children in the UK have all their meals provided by their family. Where children receive school meals, schools are required to provide good quality, healthy food that is appealing to children and which follows statutory nutritional standards. Schools should encourage families who are entitled to free school meals to take up their entitlement.

Nutrition in adolescence

The need for a balanced diet rich in vitamins and minerals continues in this age group as young people have high energy requirements from their diet as they move through puberty and undergo the final stages of growth before adulthood. However, this is also a period of increasing freedom and independence away from the family and the temptation to consume junk food high in fat and sugar, or modify the diet to reduce calorie load may be high. Eating behaviours which compromise health, such as skipping meals, extreme dieting or over-eating may begin to manifest and is something the children’s nurse/school nurse should be aware of.