Introduction

It is important to encourage children to consume a wide range of foods to optimise their nutritional status, which, in turn, promotes good health (Edmondson, 2011). Harris (2010) asserts that a child's nutritional status has been shown to have a significant impact on health, both in the present and as the child progresses to adulthood.

A recent report from the Scientific Advisory Committee on Nutrition (SACN) (2011) suggested that, while children's diets in the UK have improved over the last 15 years, there are still certain nutritional areas that are significantly lacking. These include children who have:

* Significantly low intakes of iron and vitamins AandD

* High intakes of foods high in saturated fats and sugars.

Poor-quality diets can increase the risk of obesity, which is already a growing health issue in young children (Harris, 2010) and can predispose an individual to a greater risk of developing coronary heart disease (Gidding et al, 2005) and type 2 diabetes in later life (Copeland et al, 2005).

Iron deficiency is said to be one of the most common nutrient deficiencies in the UK (Hignett, 20 1 1 ) and children whose diets are lacking in iron are at risk of developing poor cognitive and physical performance in adulthood (Pasricha, 201 1 ). Box 1 gives some practical guidelines as to how iron levels can be enhanced in childhood.

Current best practice suggests that mothers should be encouraged to breastfeed infants where possible (Jennings et al, 2011), as this and other modifiable dietary factors, including weaning and feeding style, all contribute to the development of food preference (Shim et al, 201 1 ). Early exposure to different flavours - bitter, sweet salt and sour - through breast milk and weaning can also help to determine food preferences and affect long-term health (Beauchamp and Mennella, 201 1).

Weaning

The National Institute for Health and Clinical Excellence (NICE) (2008) defines weaning as: 'The transition from an exclusively milk diet to a diet based on solid foods'. Current government guidelines state that a healthy infant born at full term requires no other forms of nutrition than breast or formula milk for the first six months (Shaw and McCrann, 2007).

A recent study by Shim et al (2011) proposed that introducing solid foods to children before six months may mean they are far more likely to develop food neophobia and to consume a limited variety of foods compared to children who were exclusively breastfed for six months.

Food neophobia is defined as 'the rejection of novel or unknown foods' (Scaglioni et al, 2011). Both neophobia and fussy eating (the rejection of a wider range of foods including novel ones) are well known barriers to healthy eating in childhood (Van der Horst, 2012). However, Harris (2010) argues that in most children these are normal behaviour patterns that will gradually resolve as the child gets older.

However, every child is an individual and some babies may be showing physical signs that they can be weaned safely from four months (Shaw and McCrann, 2007). Table 1 identifies the types of behaviour associated with readiness to wean a child.

Wright et al (2004) propose that larger infants and male children may need weaning earlier to promote healthy growth and nutritional status. There is no evidence to suggest that weaning at four months confers any significant harm to the child (More et al, 2011).

As an infant's mouth is very highly sensitive (Harris, 2010), Webster-Gandy et al (2005) propose that solid foods should be introduced at six months without delay, as this will desensitise the mouth and help to reduce the gagging and retching that is often seen when infants are offered lumpy foods.

Avoidance of lumpy foods can lead to problems with food acceptance later on during childhood (Cordain et al, 2005). Harris (2010) suggests that it is best practice for parents to introduce foods with different textures and tastes at the appropriate times. Infants are born with a natural innate preference for sweet foods (Pepino and Menella, 2005) and foods with a fatty texture (Mattes, 2009). Other tastes, such as bitter and salt, will develop as they become older. Salt should not be added to infant foods as this can cause harm (Shaw and Lawson, 2008). Table 2 gives some examples of menus incorporating different tastes and textures during the weaning period.

If foods are being rejected, Rigai (2010) suggests that parents should persevere and offer these foods repeatedly, which can be as much as eight to 15 times to promote acceptance (Briefel et al, 2004). Some parents have been known to 'hide' new foods, such as fruits and vegetables, in familiar dishes. However, Brown and Harris (2012) suggest that this practice should be avoided as the new food may be seen as contaminating the accepted food by a child with food neophobia.

It is best practice to offer foods that the child 'dislikes' on a separate plate and to encourage 'tiny tastes', where a teaspoon of either fruit or vegetable or other problem foods are offered throughout the meal (Harris, 2010). Some suggestions to encourage children to eat fruit and vegetables indude:

* Top pizza with favourite vegetables or fruits, such as canned pineapple

* Offer carrot sticks, slices of pepper and peeled apples and pears as snacks

* Mix fresh or canned fruit with yoghurt or fromage frais for dessert

* Chop dried apricots into cereal (adapted from Shepherd 2008b; Department of Health, 2007).

Offering food as a reward for good behaviour is often viewed negatively, but there is now evidence to suggest that using a chart with stickers, or words of praise can be highly effective in encouraging them to taste new foods (Cooke et al, 2011). However, if children display substantial food refusal, they may require referral to a specialist dietitian or psychologist (Harris, 2010).

Regular monitoring of child growth is vital for early identification of children with growth faltering or excessive weight gain (Goulet, 2010); for example, children who have inflammatory bowel disease may show stunted growth (O'Donaghue and Dawson, 1977). However, Hignett (Edmondson, 2011) argues that most children who show faltering growth are more likely to have issues with their food intake.

Food allergies and intolerance

Food allergy is defined as an adverse immune response to a food (NICE, 201 1) and is one of the most common of the allergic disorders seen in approximately 6 - 8% of children between the ages of one and three years (Waddell, 20 1 1 ). Some infants have a high risk of developing a food allergy because their parents or siblings are atopic (More et al, 2011).

Common food allergies seen in early childhood include:

* Cow's milk protein

* Hen's egg

* Soy

* Peanuts

* Tree nuts

* Fish

* Shellfish

* Celery

* Mustard wheat

* Kiwi fruit

* Sesame seeds (Meyer, 2008).

Symptoms of food allergy can range from anaphylaxis - which is life threatening if not treated immediately with epinephrine (epipen or adrenaline) (Cianferoni and Muraro, 2012) - to generalised symptoms that are slower in onset and may present as eczema, wheeze, mood changes, failure to thrive, gastrooesophageal reflux, diarrhoea and vomiting (Geissler and Powers, 2009).

Grimshaw (2009) proposes that such infants should be exclusively breastfed where possible and high-allergen foods should be introduced one at a time, so that any potential reaction can be attributed to a specific food. There is no dear evidence to suggest that delaying foods that are considered to be high allergens after six months of age will reduce the risk of allergy (Venter, 2009).

It is really important that food allergy is not confused with food intolerance, which Carney (2009) defines as 'an adverse food-induced reaction that does not involve the immune system, and does not produce life-threatening symptoms'. The symptoms of food intolerance tend to manifest themselves in a slower manner and include abdominal pain, nausea, vomiting and diarrhoea.

It is important to be aware that the range of symptoms in food allergy and intolerance is diverse, making diagnosis difficult (Fox et al, 201 1). If parents think their child is reacting to any specific food or foods, it is best practice to refer them to their GP for investigations with a qualified allergy specialist, rather than start an elimination diet, which could have serious nutritional consequences (Shepherd, 2012).

Social eating behaviour

According to Shaw and Lawson (2008) a five-year-old child has the ability to modify his or her eating behaviours in accordance with 'social rules'; for example, eating when others are eating, even when they are not hungry, or learning to 'clean their plate'. Harris (2010) warns that such behaviour should be discouraged as this may lead to comfort eating and obesity.

Observational studies have found that children's intake at meal times, particularly young toddlers, will vary considerably; for example, a child will eat well one day and a great deal less the next (Shaw and Lawson, 2008). This situation often causes parental anxiety, but research has suggested that young children have the ability to adjust their food intake across successive meals, which compensates for higher or lower intakes at a given meal, making their total daily intake fairly consistent (Hanley and Hutcheon, 2010).

Family mealtimes are a social activity that, in some families appears to be waning. A recent study (Hammons and Fiese, 2011) found that in families who eat five or more meals together during the week, children are 25% less likely to encounter nutritional health issues than those in families who eat less than one meal together per week. It has been suggested that having one parent present during an evening meal is more likely to encourage children to increase consumption of fruit, vegetables and dairy foods and not to skip breakfast (Scaglioni et al, 2011). Keeping mealtimes free of arguments may also encourage children to eat more of the food they are given (Burnier et al, 2011).

How much food do children need?

As a child progresses from the toddler years, Hignett (Edmondson, 2011) proposes that it is best practice to offer 'little and often'. Three small meals and two snacks per day should provide the right level of energy intake for an individual child.

The Food Standards Agency (FSA, 2007) proposes that children aged five years and older will require a wider variety of foods from the five food groups for healthy growth and development Care should be taken to ensure that portion sizes are appropriate for the child's age and body size, limiting fast foods and avoiding oversized portions (ESPGHAN et al, 2011).

Achieving a healthy balance

To optimise growth, development and to maintain a healthy weight there needs to be an effective balance between food intake and exercise.

Physical activity is defined as 'any bodily movement produced by skeletal muscles mat results in energy expenditure beyond that of resting expenditure' (Thompson et al, 2003). There is a growing body of evidence to suggest that physical activity plays an important part in the prevention of becoming overweight and obese in childhood and adolescence, and reduces the risk of obesity in adulthood (Hills et al, 2011).

It is important for parents to encourage regular exercise, which according to the Department of Health (2004) should incorporate 60 minutes of moderate-intensity exercise each day. This can be broken down into four 15-minute periods; three 20-minute periods or two 30-minute periods of exercise per day, depending on family circumstances (Shepherd, 2008b). Activities can include:

* Walking to and from school

* PE lessons at school

* Active play at break times and out of school

* Skipping, jumping, swimming, cycling, skating, dancing and family games/activities.

Conclusion

One in three children is overweight by the age of nine in the UK, and this number has increased by 40% in the last few years. If this continues nearly half of the children in the UK will be overweight or obese by 2020 (Academy of Medical Royal Colleges, 2012). It is vital for parents to promote good eating habits from an early age, and it is best practice, where possible, to exclusively breastfeed infants for the first six months, and wean them according to their individual needs using a wide range of foods textures and tastes. Parents should aim to promote regular, enjoyable family mealtimes and encourage their children to participate in regular exercise if they are to grow into happy, healthy adults.

References

Academy of Medical Royal Colleges (2012) Medical Profession united in fight to defuse obesity time bomb. Available from: www.aomrc.org.uk/itern/medicalprofession-united-m-fight-to-defuse-obesity-timebomb.html [Accessed June 2012].

ESPGHAN Committee on Nutrition, Agostani C, Braegger C et al. (2011) Role of dietary factors and food habits in the development of childhood obesity: a commentary by the ESPGHAN Committee on Nutrition. J Paediatr Gastroenterol Nuir 52(6): 662-9.

Beauchamp GK, Mannella JA. (201 1) Flavor perception in human infants: development and functional significance. Available from: http://content.karger.com/ produktedb/produkte.asp?DOI=000323397&typ=pdf [Accessed June 2012].

Briefel RR, Reidy K, Karwe V, Jankowski L, Hendricks K. (2004) Toddlers' transition to table foods: Impact on nutrient intakes and food patterns. J Am Diet Assoc 104 (Supp 11):S38-44.

Brown SD, Harris G (2012) Disliked food acting as a contaminant during infancy. A disgust based motivation for rejection. Appetite 58(2): 535-8.

Burnier D, Dubois L, Girad M. (201 1 ) Arguments at mealtimes and child energy intake. / Nutr Educ Behav 43(6): 473-81.

Cianferoni A, Muraro A. (2012) Food-induced anaphylaxis. Immunol Allergy Clin North Am 32( 1 ) : 165-95.

Clark HR, Goyder E, Bissell P, Blank L, Peters J. (2007) How do parents' child-feeding behaviours influence child weight? Implications for childhood obesity policy. J Public Health (Oxf) 29(2): 132-11.

Cooke L. (2007) The importance of exposure for healthy eating in childhood: a review. / Hum Nutr Diet 294-301.

Cooke LJ, Chambers LC, Anez EV, Wardle J. (201 1) Facilitating or undermining? The effect of reward on food acceptance. A narrative review. Appetite 57(2): 493-7.

Cordain L, Eaton SB, Sebastian A et al. (2005) Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr 81(2): 341-54.

Department of Health (DH). (2004) Choosing Health: making healthy choices easier. London: DH.

Edmonson L. (201 1) What toddlers eat really matters. Learning Curve Study Day Report. / Pam Health Care 21(3): 33-9.

Food Standards Agency (FSA). (2007) Starting solid foods. Available from: www.eatwellscotland.org/ agesandstages/baby/startingsolidfoods/index-htrnl [Accessed June 2012].

Fox AT, Lloyd K, Arkwright PD et al (201 1 ) The RCPCH care pathway for food allergy in children: an evidence and consensus based national approach. Arch Dis Child 96(Suppl2): i25-9.

Geissler C, Powers H. (2009) Fundamentals of Human Nutation for Students and Practitioners in Health Sciences. Oxford: Churchill Livingstone.

Gidding S, Dennison BA, Cochain LL et al. (2005) Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation 112(13): 2061-75.

Goulet O. (2010) Growth faltering: setting the scene. Eur J Clin Nutr 64(Suppl 1 ): S2-4.

Grimshaw K. (2009) Infant feeding and allergy prevention: a review of current knowledge and recommendations. A EuroPrevall state of the art paper. A/fergy 64(10): 1407-16.

Hanley JA, Hutcheon JA. (2010) Does children's energy intake at one meal influence their intake at subsequent meals? Or do we just think it does? Paediatr Perinat Epidemiology 24(3): 241-8.

Hanson M, Fall C, Robinson S. (2009) Early life nutrition and lifelong health. London: BMA.

Harris G. (2010) Developing positive earing habits A practical approach to sharing responsibility. A report from the Infant and Toddler Forum study day 2010. Available from: at: www.infantandtoddlerforum.org/ article_Developing+positive+eating+habits+Study+D ay+Report+2010_id-577.html (Accessed June 2012].

Hills AP, Andersen LB, Byrne NM. (201 1 ) Physical activity and obesity in children. Br i Sports Med 45(11): 866-70.

Jennings A, McEvoy S, Corish C. (2011) Nutritional practices in full day care pre-schools. iHum Nut Diet 24(3): 245-59.

Mattes RD. (2009) Is there a fatty acid taste? AnnuRev Nutr 19: 305-27.

Meyer R. (2008) New guidelines for managing cow's milk allergy in infants. / Fam Health Care 18(1): 27-30.

More J, Jenkins C, King C, Shaw V. (201 1 ) Weaning Infants onto soild foods. BDA Paediatrk Group Position Statement. Available from: www.bda.uk.com/ publications/statements/PositionStatementWeaning. pdf [Accessed June 2012].

National Institute for Health and Clinical Excellence (NICE). (2008) Improving the nutrition of pregnant and breastfeeding mothers and children in low income households. London: NICE.

NICE. (2011) Diagnosis and Management of food allergy in children and young people in primary care and community settings. London: NICE.

O'Donoghue DP, Dawson AM. (1977) Crohn's disease in childhood. Arch Dis Child 52(8): 627-32.

Pasricha SR. (201 1) Should we screen for iron deficiency anaemia? A review of the evidence and recent recommendations. Pathology 44(2): 139-47.

Pepino MY, Mennella JA, Reed DR. (2005) Genetic and environmental determinants of bitter perception and sweet preferences. Paediatrics 115(2): e2 16-22.

Rigal N. (2010) Food diversification and taste building. Arch Paediatr (Suppl 5): S208-12.

Scagolini S, Arriza C, Vecchi F, Tedeschi S. (201 1) Determinants of children's eating behaviour. Am J Clin Nutr 94(6 Suppl): 2006S-201 IS.

Scientific Advisory Committee on Nutrition (2011) The influence of maternal fetal and child nutrition on the development of chronic disease in later life. Available from: www.sacn.gov. uk/pdfs/sacn_early_nutrition_ final_report_20_6_U.pdf [Accessed June 2012].

Shaw V, McCrann U. (2007) The Child First and Always. Southampton: University of Southampton.

Shaw V, Lawson M. (2008) Clinical Paediatric Dietetics, 3rd edn. London: Blackwell.

Shepherd A. (2008a) Nutrition through the life-span. Part 2: children, adolescents and adults. Br ] Nurs 17(20): 1332-8.

Shepherd A. (2008b) Paediatrics: nutrition for babies and young children. Br J Healthcare Assistants 2(3): 132-6.

Shepherd A. (2012) The nutritional management of children following medical/restricted diets (in press).

Shim JE, Kim J, Mathai RA et al. (201 1 ) Associations of infant feeding practices and picky eating behaviours of preschool children. / Am Diet Assoc 1 1 1(9): 1363-8.

Thompson PD. (2003) Exercise and physical activity in the prevention and management of atherosclerotic and cardiovascular disease. A statement from the Council on Clinical Cardiology (Sub committee on Exercise, Rehabilitation and Prevention) and the Council on Nutrition, Physical Activity and Metabolism (Subcommittee on Physical Activity) Circulation 107(24): 3109-16.

Tsuji M, Nakamura K. Tamai Y et al. (2012) Relationship of intake of plant-based foods with 6-n-propylthiouracil sensitivity and food neophobia in Japanese preschool children. Eur iof Clin Nutr 66: 47-52.

Van der Horst ?, (2012) Overcoming picky eating. Eating Enjoyment as a central aspect of children's eating behaviour. Appetite 58: 567-74.

Venter C. (2009) Cow's milk protein allergy and other food hypersensitivities in infants. J Fam Health Care 19(4): 17-23.

Waddell L. (2011) Living with food allergy, ioumal of Family Health Care 21(4): 21-8.

Webster-Gandy J, Madden A, Holdsworth M. (2005) Oxford Handbook of Nutrition and Dietetics. Oxford: OUP.

Wright CM, Parkinson KN, Drewett RF. (2004) Why are babies weaned early? Data from a prospective population cohort based study. Arch DL· Child 89(9): 813-6.

Author affiliation:

Alison Burton-Shepherd PGCAP (ed) FHEA MSc BSc (Hons) RGN ÇTCH)

Queen's Nurse

Department of Primary Care and Child Health, Florence Nightingale School of Nursing and Midwifery, King's College London

Correspondence to: alison.shepherd@kcl.ac.uk