Nutritional Guidance for Early Years: food choices for children aged 1-5 years in early education and childcare settings

3 Additional information

3.1 Oral and dental health for pre-school children

As a carer, you can work with young children and parents to help develop good oral and dental health habits.

Key messages for pre-school children to improve dental health include:

Toothbrushing

• Toothbrushing should begin as soon as the first teeth erupt.
• Children should brush their teeth twice a day using toothpaste containing 1,000 ppm fluoride.
  No more than a smear of fluoride toothpaste should be used for children under 2 years and a small pea-sized quantity for children 2 to 6 years.
• Children will need supervision with toothbrushing until they are 6 to 8 years old.

Registering with a dentist

• Children should be registered with a dentist no later than 6 months or as soon as the first tooth erupts. If parents have not registered their child with a dentist by the time they come to your care, ask them to do so.
• Children should have regular check-ups with a dentist.

Diet

• Choose foods low in added sugars. Foods containing any added sugars should be eaten only at meal times.
• Water and plain milk should be the only type of drink given between meals.
• Drinks should be given from a cup or glass, with or without a straw, and not from a bottle.

For further information on the prevention of tooth decay in pre-school children see An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland. ²⁴

3.2 Snacks

Children need a varied diet to ensure that they get all the nutrients they require for growth and development. Pre-school children often have small appetites and need regular meals with snacks in between (see section 2.1). Snacks should be nutritious and low in added sugars to prevent tooth decay.

There are some snack foods that can be harmful to children's health if they are eaten frequently. These include soft drinks, sweets, chocolate confectionery, chocolate and cream-filled biscuits, sugary pastries, sugary desserts, highly-sweetened cereals, and sugary and sugared sticky yoghurts.

These types of snacks should not be provided in the pre-school care setting. If they must be given to children, they should be eaten at meal times only.

Suggestions for nutritious snacks

• Fruit: mouth-sized chunks, cubes or slices of apple, pear, satsuma, orange, banana, kiwi, melon, strawberries, sliced grapes, peaches and plums ( for child-sized portions, see Appendix 4).
• Raw vegetables: carrot, pepper, celery, cucumber, sliced cherry tomato, red cabbage, turnip, radish, courgette, broccoli.
• Toast, breads, rolls, baps, French bread with a small amount of butter or spread; mini sandwiches with marmite, cheese, tuna, banana, salad or thin slices of meat; pitta bread pockets cut into small slices; plain or with spread, e.g. olive or sunflower oil spread.
• Bread sticks - on their own or with a dip or soft cheese; homemade pizza triangles.
• Oatcakes, rice cakes, crackers, crispbreads, melba toast: plain or with butter or spread, e.g. sunflower or olive oil spread.
• Natural yoghurt with fruit or fromage frais - on its own or as a dip.
• Muffins, plain, potato or cheese scones, crumpets, pancakes, plain buns, plain popcorn, low-sugar breakfast cereal.

Note: crisps or corn snacks, e.g. Quavers, Golden Lights, Wheat Crunchies, tortilla chips or Twiglets, can be offered as part of a snack or meal option as an alternative texture and taste, e.g. beside a filled sandwich or salad dish. However, they are high in salt and fat and therefore pre-school children should not be given them any more than twice a week (see section 2.3).

CASE STUDY

Happy Jack Project

The Happy Jack project is operated by Edinburgh Community Food Initiative ( ECFI) and works with families with children between 4 months and 4 years through 12 Children and Family Centres in Edinburgh. The project provides children with over 1,600 portions of snack fruit and 2,400 pieces of fruit to take home every week free of charge. In addition, fruit stalls have been established within each centre to provide low-cost, good-quality fruit and vegetables to parents.

The project provides a 5-week healthy eating cooking course for staff and parents which covers issues such as reading food labels, shopping on a budget and increasing the family fruit and vegetable intake.

All centres have received the Pip Project Activity Pack, which was created by staff at ECFI and contains recipes, arts, crafts, songs, games and rhymes based on the most celebrated seasonal and cultural events. The pack is designed to complement the five key areas of the pre-5 curriculum and provides advice and information on key nutritional issues for this age group.

The Happy Jack Project works in collaboration with a range of other local initiatives and partners including Bookstart, music and movement groups, Lothian and Edinburgh Environmental Partnership and oral health staff.

3.3 Drinks

It is important for pre-school children to have plenty to drink to help their bodies to function properly, keep cool and prevent constipation.

• Children should be encouraged to drink plain, still water at any time throughout the day. Plain, still water quenches thirst, replenishes body fluid, does not spoil the appetite and is not harmful to teeth.
• Milk and water should be the only drinks taken between meals. From 1 year of age, whole cows milk should be the main milk drink until the child is at least 2 years old. From age 2, semi-skimmed milk can be introduced as a main milk drink, provided the child is eating well. Fully skimmed milk is low in energy and low in some nutrients and for this reason is not suitable as a drink for children under the age of 5. From 5 years of age fully skimmed milk can be given. When only one type of milk is provided (e.g. in the nursery setting) it should be whole milk.
• Fresh fruit juice is a good source of vitamin C and is best given with breakfast or a main meal to help with the absorption of iron. Fresh fruit juices are acidic and can cause dental erosion and therefore should be served in a cup, not a bottle, and at meal times only.
• Children should be strongly discouraged from drinking sugared drinks frequently. There are a number of reasons why these are unsuitable for pre-school children: they contribute to dental disease, they are a poor source of nutrition, they tend to displace other more nutritious foods, and they can result in poor energy balance. Examples of unsuitable drinks include: fizzy (carbonated) drinks including water, still sugary drinks, squashes and flavoured waters, cartons of sugared drinks, cordials for milk drinks.
• Fizzy, carbonated drinks which are sugar free are harmful to teeth due to their high acid content.
• Tea and coffee are not recommended for children under 5 because they contain tannin and caffeine. Tannin interferes with the absorption of iron.

3.4 Physical activity

All children, including children with disabilities, should have the opportunity to take part in physical activities, and the pre-school setting is important in contributing to the recommendation for at least 1 hour of physical activity a day. Young children, given the chance, will do this as part of spontaneous play, allowing them to have fun as well as improving physical health and social skills.

Encourage children to be active and plan opportunities for structured activity and unstructured active play on a daily basis. Having access to a range of physical activities encourages young children to develop positive attitudes to the benefits of active living.

Ensure that activities are appropriate to children's age and stage of development and check that links are made with the Curriculum Framework for Children 3 to 5. ⁷

You will find further information and lots of ideas in Let's Make Scotland More Active. ²⁵

3.5 Vegetarian and vegan diets

Vegetarian diets

Vegetarians don't eat fish or meat, but most will eat animal products, such as eggs, milk and dairy products. Provide food from the main food groups using the menu guidance. Choose alternatives to meat such as eggs, soya products (e.g. tofu), lentils, beans, including baked beans, chopped nut and nut pastes, seed pastes, meat substitutes (e.g. soya mince, quorn) and chickpeas (e.g. falafel, hummus).

Ask parents/guardians about foods that the child is familiar with at home, or about particular foods to be avoided, e.g. gelatine and rennet.

Vegetarian meals and snacks are suitable for all children.

Vegan diets do not include any food from animal sources, therefore, in addition to meat and fish, they exclude dairy produce, eggs and honey. This makes meeting the nutritional needs of the child more complex and they should be discussed with the parents and/or guardians.

Meeting iron requirements on a vegetarian diet

As meat is one of the main sources of iron it is important that vegetarian and vegan children eat other iron-rich foods such as wholemeal bread, breakfast cereals, pulses, beans, peas, dried fruits, fortified cereals, and dark green vegetables, especially broccoli. Fresh fruit and vegetables and fresh fruit juice are rich in vitamin C, which enhances the uptake of iron in the body. Tea and coffee interfere with the absorption of iron and for this reason are not suitable for young children.

3.6 Food choices and religious faiths and beliefs

Families may choose to exclude, include, or prepare foods in a particular way according to their religious faith and beliefs. Appendix 5 provides guidance on food choices for specific religious groups. This gives general guidance only as there will be individual differences and varying levels of adherence to religious laws which should be discussed for each child with his or her parent or guardian.

3.7 Children with special needs or therapeutic diets

Some children will need the food they are offered to be modified. There are a number of possible reasons for this, e.g. special needs and therapeutic diets, including those for allergies.

Children with special needs may need to have their food prepared in a particular way to make it easier to eat. They may use specially designed cutlery. In some cases they may need to have a structured eating pattern.

For children on a therapeutic diet, the parent/guardian or registered dietitian will supply the staff or carer with details of the child's dietary needs, including suitable food choices for meals and snacks, foods that should be excluded or specifically included, or supplements that are required.

Therapeutic diets for food allergies are not uncommon in pre-school children. Foods commonly associated with allergies are milk, wheat, peanuts, fish, soya, eggs, shellfish, citrus fruits, seeds and nuts. A wide range of symptoms can occur when a child is exposed to an allergen in food, ranging from a mild reaction to a very rapid and severe response.

When a child has a severe allergy to a particular food you may decide to minimise the risk of exposure by avoiding having the food/ingredient in the pre-school setting. In severe cases it is essential that there is regular access to up-to-date advice from a registered dietitian because ingredients in processed foods change frequently.

All children, regardless of special or therapeutic dietary needs, should enjoy food and choosing and experimenting with different foods.

3.8 Vitamin supplementation

Some children may receive vitamin drops, containing vitamins A, D and C. This is the responsibility of parents and guardians and can be discussed with them. However, it will be useful for staff and carers to be aware of current advice on children who may benefit from vitamin drops.

For children aged 1 to 5, the current advice for vitamin supplements is to take vitamins A, D and C. ^26,27 Children who are at risk of vitamin deficiency include: persistent poor eaters, children who eat a very limited number of foods, those on restricted diets by choice, vegans and children on restricted diets because of food allergy or intolerance.

There are important issues regarding intake of vitamin D and vitamin D requirements in the Scottish population because we are so far north and have so little sunlight, especially during winter ²⁸ ( see Appendix 2).

There is no need to give young children aged 1 to 5 years other more complex multivitamin and/or mineral preparations unless they are on a special or therapeutic diet and it has been advised by a doctor or registered dietitian.