Healthy eating in schools: supplementary guidance

Section 2
Ensuring appropriate food and drink choices for all children and young people

What is a special diet?

A special diet is where alternative food and drinks are required as a result of a specific need and cannot be met by the options generally available for school lunches, or other food provision in school. This might be due to an allergy, intolerance, medical need, or one that is associated with the specific needs of a child or young person with an additional support need. In some cases, special dietary requirements will need to take account of children and young people's religious and cultural backgrounds.

Specific issues for those with additional support needs

It is important to recognise that children and young people who need assistance with eating or drinking, or who require food with modified consistency, and those who are selective eaters, by and large have the same energy and nutrient requirements as their peers. Ideally, therefore, they should all be provided for within the same overall provision which is healthy and nutritionally balanced, as defined by the Regulations. Helping children and young people with complex physical, emotional, behavioural, and medical needs to meet their nutritional requirements may be harder to achieve than for those without these conditions. It can be much more difficult to ensure that consumption (as opposed to provision) is meeting every child's nutritional needs. In practice, it is important for schools to identify and cater to the dietary needs of children and young people with medical or psychological conditions, for whom it may not be possible or appropriate to conform to dietary guidelines intended for the population as a whole. This might include children with defined medical conditions such as cerebral palsy and downs syndrome as well as conditions such as ASD, or learning difficulties. It is not possible to list all of the conditions or issues to which special dietary needs might apply. Each child must be addressed individually.

School lunch provision

Lunchtime in school provides a rich opportunity for learning, allowing skills and experiences to be developed in a positive, supportive environment. This is explored further in section 3.

School lunch menus

School lunch menus are required to meet statutory nutrient standards set within the Regulations. These standards are set to ensure the average school lunch provides around a third of the daily nutritional requirements of primary and secondary age children. The standards are designed to meet the needs of the majority of the school population. Therefore children and young people with special dietary needs may need to be catered for individually.

It is important, of course, to meet the specific needs of children and young people with medically prescribed diets, and these are exempt from the Regulations. For example, it may be appropriate for a child to have full fat milk as opposed to semi-skimmed milk if they are underweight due to their medical condition. Schools are required to take reasonable steps to meet these needs.

Many special schools cater for both primary and secondary aged pupils and often offer the same menu to all. There are different sets of nutrient standards for primary and secondary pupils which reflect the differing nutritional needs of the age groups. Caterers must ensure that where the same menu is being offered to both primary and secondary children, that this meets the corresponding standards, ie a school lunch provided to a primary pupil must comply with the standards for primary schools; and a school lunch provided to a secondary pupil must comply with the standards for secondary schools. As a result, portion sizes will need to vary for primary and secondary pupils. Schools and local authorities should also work together to ensure there are age appropriate choices available. This is particularly important for young people of secondary age to allow the development of their social skills and the ability to make independent choices.

Special diet policies and procedures

Clear procedures for the provision of special diets are essential to ensure that the needs of each individual can be met by school caterers. The procedures ensure that a request for a special diet is handled in an efficient and appropriate way. Each local authority should have a special diet policy in place following recommendations with Hungry for Success ¹¹ . Schools should ensure staff are familiar with the policy and procedures contained within it, that procedures are followed, and that parents are made aware of this.

Where children and young people are provided with particular products on prescription, for example gluten free pasta, it may be possible for parents to provide a small amount of these to school caterers to use when preparing a meal. This will help to increase the choice and variety of foods that can safely be provided for a child or young person who has specific dietary restrictions.

In some circumstances, parents may request that their child is to follow a special diet even though there are no specific medical grounds for this request. For example, there is some belief that dietary exclusion of caseins and/or gluten will benefit children with ASD. Research has shown that there is insufficient evidence to support significant benefits with these interventions and as a result the doctor will be unable to prescribe gluten free foods or nutritional supplements. Schools should respect parents' wishes and discuss fully whether the request can be met (refer to local policy on medically prescribed diets in schools). The school may request that the school doctor or paediatrician is involved to ensure they receive the necessary advice and supervision. For more information on diet and ASD, see the websites of the British Dietetic Association at www.bda.uk.com where a factsheet on diet and ASD can be downloaded, or the Scottish Intercollegiate Guidelines Network at www.sign.ac.uk for a copy of the clinical guidelines on the assessment, diagnosis and clinical interventions for children and young people with ASD. A leaflet for parents and carers is also available from this website.

Structure

The importance of catering procurement in supporting good nutrition in a school setting should be recognised. It should be noted that those purchasing and preparing food do so on behalf of children and young people in their care. As a result, the type and quality of food purchased should meet the health and wellbeing needs of all children and young people.

It is recognised that catering procurement structures in local authorities can sometimes make it difficult to procure specialist food and drinks required for those with a special diet. It is therefore useful to understand the management structure that delivers the school lunch service in your area in order that children and young people are able to benefit from all that the Act is intended to deliver. Two different examples of structure are provided below:

• Internal Provider: where the service is delivered by an in-house caterer the management structure is likely to be either part of the education department or it may be managed for education by another local authority department. In both cases there will be a budget and/or Service Level Agreement set for the delivery of the service. Where service improvements are identified by the headteacher this will often require negotiation. These should take place initially with the area manager who has responsibility for catering.
• External Provider: the external provider covers a range of structures, however it requires a separate legal organisation delivering the services for the local authority through a binding contract. The external contractor will deliver only what is specified in the contract. If a headteacher has significant service problems, this would normally be dealt with by a contract administrator employed within the local authority.

Budgets for catering

Catering as an activity within the school will be an identified cost centre with a budget set for labour, food and other costs. The catering manager will be accountable for performance within budget and may have minimal flexibility to take on board genuine requests which will require additional labour, food or equipment costs without approval being sought. At the same time the local authority is bound to meet reasonable requirements for the child's development and this may impact on the initial budget. Where there is an additional service requirement to meet actual pupil need the headteacher should provide the catering manager with the necessary information so that this can be presented as a budget pressure or escalation within their own structure when this is more appropriate.

Partnership working to ensure optimal nutritional intake

For a child or young person with additional support needs affecting their diet and nutrition, a multidisciplinary approach is essential for the management of their eating and drinking. This should include parents, education staff, catering staff and health professionals (dietitian, speech & language therapist, occupational therapist, physiotherapist, and paediatrician), where appropriate. It is good practice for all those involved to be clear about their specific role and contribution, and for this to be clarified from the outset. The views of children and young people should also be sought.

For children and young people who are being provided with a special diet, it is essential that a member of staff is identified as taking key responsibility to ensure that the lunch provided is nutritionally complete. This could involve liaison with school cooks, parents, speech and language therapists and a dietitian. Ideally, a dietitian should be consulted when changes are made to the planned menu to ensure provision remains appropriate, or to provide guidance on suitable foods for children or young people who need to gain or lose weight. For those who have difficulties with eating, drinking and swallowing, a speech and language therapist and dietitian will assess and provide guidance and training on foods and drinks that are appropriate, and how these should be prepared. Children and young people should also be involved and informed when changes are being made as far as possible so that they are prepared for this happening.

Catering staff have a huge role to play in preparing and providing food and drinks for children and young people in school. Important nutrients can be diluted when the consistency of a food is changed, therefore catering staff need to have an understanding of the modifications made to food and how this can impact on the quality and availability of nutrients contained within it. Training, good quality information and regular liaison with school staff, health professionals and parents is paramount to ensure the catering staff are well informed and have the necessary skills and confidence to meet the needs of children and young people with a special dietary requirement.

It is vitally important that catering staff are given all the necessary information in writing for each child with a specific dietary need. This not only helps to ensure their needs are provided for, but also allows this information to be available to others in the event of staff absence or change. The information should be high quality and with sufficient detail for the cook to be able to make the necessary modifications. This information should be reviewed at least annually, or when the dietary needs of the child or young person change.

It is good practice to have regular meetings with the caterer to review and evaluate the service being provided to children and young people. Regular meetings between the school cook and parents can also be beneficial to develop trust, confidence and ensure that the staff are fully aware of a child's changing needs.

Presentation of food

Presentation of food is a significant part of the enjoyment of meals and should not be neglected. This is particularly important where food requires texture modification. Foods should be modified (puréed or mashed) separately so that children and young people can identify the different foods and appreciate colours, textures and tastes. Likes and dislikes can then be distinguished and expressed. Food moulds are commercially available and can be used in conjunction with commercial thickeners to produce texture modified food so it looks similar to its solid counterpart. This ensures a more positive mealtime experience for those on a modified diet ¹² . A speech and language therapist will provide specialist guidance in this area. A summary of the national food and drink descriptors for texture modification are found in Annex B.

The level of presentation of food on the servery should be given high priority to ensure that it is fresh, appetising and appealing. The servery should be at an appropriate height to allow food to be seen visually by children to help aid their selection of food. Other useful tips to improve presentation include:

• Individual dishes for desserts can look more appetising than one large container. that children receive a serving from
• Colourful plates and crockery can make food look more appealing.
• Chop fruit rather than always serving this whole.
• Different foods should be kept separately on the plate as far as practical.
• Position food on the servery to ensure that healthier options are given the most eye catching space and are within easy reach.
• Using visual representation of food (such as symbols) to support young people in making choices (see section 4 for further advice on this).

Consultation and engagement with children and young people

Staff, and specifically catering staff, should be encouraged to seek regular feedback from children and young people, and from their parents, about food provision in order to identify and address any areas for improvement. Carrying this out on a regular basis will mean everybody can become accustomed to giving regular feedback, which can be used to improve and shape the provision offered.

Useful tips

• Designate a lead member of staff who has an overview of what is happening with school food provision and provides leadership and coordination.
• Have processes in place for recording day-to-day issues or one-off concerns with the school food provision. This will act as a reference for future discussions and a way for staff to input into food development on a daily basis.
• Allowing the cook to spend time getting to know the individual and their specific needs can be beneficial so they have a better understanding of the child or young person's additional support needs.

Snacks and drinks

Where snack activities are part of a child or young person's learning experience it provides the opportunity for children and young people to develop social skills, make choices, and learn about good nutrition. When snacks and drinks are provided by the school or purchased from a school tuck shop, the school has the responsibility to decide what kind of snacks will be offered and how these are presented. Offering healthy options should be a prime consideration.

Any food or drinks provided by a school outwith lunchtime are required to meet the Food and Drink Standards Outwith Lunch , which are part of the Regulations. These are shown in Annex A. Further information about these standards can be found in the Healthy Eating in Schools - A guide to implementing the nutritional requirements for food and drink in schools (Scotland) Regulations 2008.

Deciding what snacks and drinks to offer must balance the requirements of the Regulations, with the needs of children and young people. It is important, of course, to meet the specific needs of children and young people with a special dietary need. It may also be necessary to provide snacks or drinks which do not meet the Regulations due to a child or young person's physiological or psychological condition. Where this is the case, it should be agreed by staff as appropriate. This will depend on the needs of the individual. However, this does not mean that all children and young people should regularly receive food and drinks that do not meet the standards where there is no sound reason for doing so.

Planning snack choices for a week or several weeks at a time can help to offer variety, different tastes and textures. Involving children and young people in this planning will ensure that what is offered takes account of their likes and dislikes, and allows for choice and independence. It is beneficial for children and young people to be involved in shopping, preparation and budgeting for snacks. Such activities provide the opportunity to develop a wide range of skills and learning to in a real life context. Staff can act as positive role models by eating snacks with children and young people.

When choosing snacks and drinks to serve, schools should consider oral health. Frequent exposure to sugar damages teeth, therefore food and drinks that have a high sugar content such as fruit juice should be limited. It is preferable to restrict these to mealtimes. It is recognised that all children and young people's tastes and needs are different, but here are some suggestions for snack choices that may be useful:

• Any fresh or tinned fruit. Dried fruit such as raisins, sultanas, apricots, dates and figs may also be provided to offer variety, but it is advisable to keep these to meal times due to their high sugar content and the effect on teeth.
• Raw vegetables such as carrots, celery, cucumber, peppers or tomato can be served with dips made from for example fromage frais and soft cheese, hummous, yogurt and cucumber, avocado and salsa.
• Any type of bread including white, brown or wholemeal bread, fruit bread, crumpets, teacakes, muffins, fruit buns, malt loaf, bagels, pitta bread, raisin toast, and scones.
• Sandwiches made with any type of bread. Suggested spreads and fillings include: cheese, creamed cheese, cheese spread, hard boiled egg, peanut butter*, banana, hummous, mashed avocado, lean meat, tinned fish, a vegetable or salad such as tomatoes, lettuce, cucumber, peppers, watercress and combinations of any of these. Toasted sandwiches can also be made.
• Plain biscuits such as crackers, oatcakes, rice cakes, melba toast, and crispbread that meet the savoury snack criteria in table 1 in Annex A.
• Plain popcorn without added salt or sugar.
• Dairy foods such as yogurts, small portions of cheese cubes, frozen yogurt, custard and rice pudding.
• Breakfast cereals such as rice snaps, wheat biscuits and cornflakes.
• Vegetable based soups.
• Unsalted nuts* and seeds.

*where there are no children with allergies.

Snack Policy

Developing a snack policy can be very beneficial. This will help to ensure all staff are aware of most up to date regulations and guidelines, and provide a consistency of approach to provision across the school.

Case study example: Snack Policy - St Andrews School, Inverurie The snack policy and guidelines for St Andrew's School was primarily devised by the Nursery Nurses in consultation with the teaching staff and management team. It was developed to provide a consistency and continuity throughout the school to ensure a varied snack, which is nutritionally balanced for all our children and young people, irrespective of individual limitations. These limitations cover a wide range, for example: Medical issues such as problems with swallow, texture, non-oral feeding, or conversely they may present with Pica, which inhibits them from distinguishing between food and non food substances. Restricted choice due to specific medical diets, such as gluten or lactose free. Restricted choice due to Autistic Spectrum Disorder ( ASD). The food and drink preferences and personal choices of each child are respected and the communications of all children and young people, especially those who are non verbal are dealt with extremely sensitively. Children and young people are regularly given the opportunity to be exposed to and experience new foods, drinks and textures through all their senses to enrich their lives.

A sample snack policy, from the case study example above is shown in Annex C.

Drinks

It is important that all children and young people have access to adequate fluid intakes throughout the day. To ensure they are well hydrated they should have about 6-8 glasses (of around 250ml) per day with 3-4 glasses being provided at school.

Being well hydrated can help reduce or alleviate symptoms for those suffering with conditions such as urine infections, bed or daytime wetting, and is particularly important in those who suffer from constipation. There is also evidence that it can lead to improvements in concentration levels and behaviour in class. Children should be encouraged to drink at regular intervals as many may not recognise the signs of thirst or may be unable to communicate their needs. Support should be provided to those who are unable to drink independently ^{13, 14} .

The drinks provided at school should comply with the Drink Standards for Schools. These are shown in Annex A. For those children who have higher nutritional requirements or are underweight, full fat milk or other prescribed fortified drinks can be provided. Children who are unable to safely drink normal fluids should have them thickened to the desired consistency as advised by the speech and language therapist or dietitian. It is a common misconception that these thickened fluids do not quench thirst. They will provide the same amount of fluid to the body as non-thickened drinks.

Oral health

Key oral health messages for children and young people should be followed:

• Being registered with a dentist and having a check up every 6 months.
• Encourage a good oral health routine by brushing the teeth twice-daily using fluoride toothpaste and always before bed (1000ppm of fluoride in toothpaste for children aged less than 7 years and around 1500ppm of fluoride in toothpaste for over 7 years). Assistance may be required for those unable to brush their teeth independently.
• Spit out excess toothpaste, don't rinse mouth out with water.
• Cut down on sweetened foods and drinks and try to limit these to mealtimes if possible.

Specific considerations which may be prevalent in some children and young people with additional support needs include:

• Drooling: can cause irritation of the skin, increased risk of oral infection, bad breath and dehydration. Treatments options should be discussed with the dentist or oral hygienist.
• Bruxism: can lead to pain and infection. Bite guards may be helpful.
• Dental Erosion: can occur in individuals with GOR, frequent vomiting, rumination and those who consume large quantities of soft drinks.
• Dry Mouth: Sufferers are more prone to dental decay, infection and periodontal disease. Use of saliva substitutes is often beneficial.
• Non-oral feeding: Good mouth care should be common practice as the swallowing of saliva laden with bacteria from a neglected mouth is a common cause of chest infection in these individuals. Dental erosion due to GOR and dry mouth are also common ¹⁵ .

A dental health professional should be consulted regularly where there are concerns about the oral health of any child or young person. They will be able to provide specialist advice and practical solutions.

Selective eaters

Selective eaters tend to limit the variety of foods they will eat, often avoiding certain food groups altogether. Some individuals also require food to be prepared in a certain way, use specific utensils to eat food, or eat in a certain type of environment. Some children also have a fixation on packaging or brands of food or drinks. Children and young people may be selective eaters for a number of different reasons including medical history, digestive problems, anxiety and conditions such as ASD. It is essential that a dietitian or medical professional is involved to ensure the child or young person is getting sufficient amounts of essential nutrients, or is not over-eating causing problems with excessive weight gain.

For children and young people who are selective eaters, the focus should be on extending what is acceptable to children and young people to include healthier options. It may be possible to introduce new food gradually. This can be built up over time, starting with toleration of a new food on the child's plate first. Staff being patient, understanding, tolerant and developing a trusting, positive relationship with children and young people is key to success. Therefore these experiences should be carried out sensitively, and with good judgement on what is appropriate and when.

A child may experience difficulties with eating a variety of food and drinks. This could be due to difficulty in making sense of the feeling of the food in their mouth or reacting to strong tastes in their mouth. Typically, children who are selective eaters will stick to plain, bland food of very similar texture and they find it difficult to expand their food choices.

Food can often be used as a sensory part of play to expose children to new foods and build up their acceptance of these. For many children who have difficulties accepting different foods into their mouth it can be useful to give them experience of touching and feeling food with their hands, which in turn allows opportunity to smell food stuffs. This is based on the knowledge that at birth sensations in the mouth are more highly developed than in any part of the body and it is known that there are twice as many sensory receptors in the mouth as there are in the hands. Therefore the experience of textures in the mouth can be overwhelming for a child, so they avoid the textures/tastes that they dislike.

It can be useful to think of the play experience in four stages: acceptance, touch, smell and taste. The opportunity to experience food textures in the hands in a play situation can help the child to tolerate new textures in a "safe" situation without the pressure of eating ^{16, 17} . Providing a non-threatening play experience of textures in the hands can help to reduce the sensitivity of reactions in the mouth.

Practical food activities such as shopping, touching and cutting can also help with acceptance. Regular communication with parents about these activities is important so that they can help to replicate and reinforce the experience at home.

Foods and drinks involved in therapy

In some circumstances, particularly for children and young people with certain medical conditions, it may be appropriate to use foods that do not meet the Regulations as part of a speech and language therapy assessment. For example, corn snacks can be used for bite-dissolve texture. This would be carried out to explore the child or young person's ability to safely manage different food textures and consistencies in order to progress their eating and drinking skills.

Food and drinks as treats or rewards

Food, and in particular sweets or confectionery should not be used as treats or rewards for good behaviour or for working hard. This practice provides an inconsistent message about healthy choices. Appropriate alternatives should be sought, for example, playing a game outdoors, stickers, certificates, or being given special jobs or tasks to do that they enjoy.

As stated in the Healthy Food in Schools guidance, food and drinks as part of social, cultural or recreational activity, for example, school discos, sports days or cultural events such as school-organised Burns suppers are exempt from meeting the regulations. However, it is recommended that all those with a role to play in organising these events would still consider, encourage and promote healthier options in keeping with the ethos of a health promoting school.

More information on special diets and eating and drinking challenges can be found in the Caroline Walker Trust guidelines 'Eating well: children and adults with learning disabilities'.