Setting the Table Guidance

4 Meeting the needs of all children

4.1 Special dietary requirements

It is important to consider the nutritional needs of the children in your care, including those with special dietary requirements.

Children with special dietary requirements may require exclusion or inclusion of specific foods or ingredients for a variety of reasons: religious or cultural beliefs, food allergies, intolerances or modified diets for other medical reasons. Children with special dietary requirements should be included in meal and snack times with other children as far as possible. Only where a risk assessment concludes that a significant risk remains despite adequate training and supervision of meals and snacks times, would a child need to eat their meal separately to other children.

Information about special dietary requirements should be discussed with parents and carers, and updated regularly in the child’s care plan to ensure their dietary needs are met. It is important not to exclude foods from a child’s diet without a valid reason as this may lead to unnecessary restrictions in their diet.

Parents and carers may be able to help the childcare setting by sharing guidance already provided by a healthcare professional. Childcare providers are not expected to be experts. Advice and guidance from appropriately qualified health professionals should always be sought if required to help with menu planning.

The information in this section is a general guide to the more common special diets and includes key points to consider when managing dietary requirements in childcare settings.

4.2 Food for religious faiths and beliefs

Children and their families may exclude certain foods or only eat foods prepared or cooked in a particular way according to their religious faith. Fasting is common in many religions, although younger children tend to be exempt. It is important to be aware how this may affect children at meal and snack times and ensure where possible that an inclusive approach is used.

Compliance with these restrictions may vary between denominations, branches or even families. Childcare settings should discuss the provision of food for any children where their religious faiths or beliefs require consideration during the menu planning process and at meal and snack times.

Some faith groups will follow a vegetarian diet due to both religious customs and personal choice. Section 3.3 provides support when providing vegetarian menus.

Relevant HSCS:

1.37 My meals and snacks meet my cultural and dietary needs, beliefs and preferences.

1.19 My care and support meets my needs and is right for me.

1.34 If I need help with eating and drinking, this is carried out in a dignified way and my personal preferences are respected.

3.15 My needs are met by the right number of people.

5.17 My environment is secure and safe.

4.3 Food allergies and intolerances

Food allergies

An allergic reaction occurs when the body’s immune system mistakenly reacts to a food or substance that is usually harmless. The food or substance that the body reacts to is known as an allergen. The most common foods associated with food allergy are provided in Section 2.5.

Most allergic reactions are mild and may cause a variety of symptoms, often involving the skin (for example, an itchy rash, hives and/or swelling of the lips, eyes or face), stomach or digestive system (such as vomiting, abdominal pain or diarrhoea). Sometimes allergic reactions can involve the airways, breathing and/or circulation (anaphylaxis), which can be potentially life threatening.

Allergic reactions are often unpredictable, can vary over time and may present differently between children. When caring for children with a diagnosed food allergy or allergies, childcare settings should take an individualised approach to understand each child’s needs.

If the child has been diagnosed with a food allergy by a health professional, the family may have an allergy action plan, and prescribed allergy medicine(s). This action plan should be shared with the childcare setting and food service provider, and include information about the child’s possible symptoms and how to treat a reaction (as well as written consent for administration of allergy medication and when to seek medical attention). This information should be recorded on a care plan, updated regularly and should be communicated to all practitioners. Example allergy action plans are available from the British Association for Allergy and Clinical Immunology (BSACI).

Regular communication with parents and carers is important to ensure a child’s care plan is up to date.

Allergy medicines typically include an antihistamine, but possibly also a blue inhaler with spacer device and/or adrenaline autoinjector devices such as an EpiPen. The allergy action plan may include details of how to use the device, but settings should also be trained in the use of the specific brand of device the child has. Childcare settings should speak to parents and carers who may be able to liaise with the health professional about accessing training for specific devices.

Allergy medicines should be accessible at all times to all practitioners, not locked away, and should be protected from direct sunlight and temperature extremes. The container for the medicines should be clearly labelled with the child’s name. It is important to ensure all medicines are in date and practitioners have a system in place to check expiry dates regularly. In the case of autoinjector devices, two devices should be available as a second dose may be required.

The Care Inspectorate provides guidance on the management of medication in daycare of children and childminding services.

If a child has not yet been assessed by a health professional but a food allergy is suspected, you should advise parents and carers to visit their GP or discuss their concerns with a health visitor.

Training for childcare settings in allergy management is sometimes available from the local authority and other providers such as The Royal Environmental Health Institute of Scotland (REHIS), Food Standards Scotland, Allergy Action, and Anaphylaxis UK. More information about allergy training can be found in Section 5.8.

Food intolerances

Food intolerance is different to food allergy and usually occurs when the body has difficulty digesting certain foods or ingredients in food. Intolerances do not involve the immune system and are not life threatening. Food intolerances cause unpleasant symptoms such as abdominal pain or discomfort, diarrhoea, bloating, constipation, red rash, itching or eczema flares. It is possible for individuals with food intolerances to tolerate a small amount of the food before they develop symptoms.

Some common food intolerances include:

• Lactose intolerance (lactose is the sugar found in animal milk, e.g. cows’ milk, goats’ milk and sheep’s milk and can be found in foods or drinks containing animal milk, e.g. yoghurt).
• Gluten intolerance or sensitivity (gluten is a protein found in wheat, barley and rye). It is important to note that gluten intolerance is different to coeliac disease. More information about coeliac disease can be found in Section 4.4.
• Intolerance to some food additives or chemicals.

The diagnosis of food intolerances can be challenging. If a food intolerance is suspected, you should encourage parents and carers to keep a diary of foods eaten and the symptoms experienced, which can then be discussed with a health professional. This can be a useful way to highlight patterns between foods and symptoms.

It is important not to exclude foods for prolonged periods due to suspected allergy or intolerance without input from an appropriate health professional, as this can result in an unnecessarily restricted diet, which could have a negative impact on nutrition.

Food allergen labelling

Under UK food law, there are 14 food allergens that must be highlighted on labels of all pre-packed and pre-packed for direct sale (PPDS) food. However, there are other food allergens not included in these 14 allergens and they will not be highlighted on a label. If a child has a known food allergy, it is important you know which food(s) to avoid and to check all food labels carefully.

Precautionary allergen labelling (PAL) includes wording on labels such as, ‘may contain’ or ‘made in a factory where the allergen might be present’. They all mean the same thing: that there is a risk of the unintentional presence of an allergen in a food product due to the allergen entering the product accidentally, or through cross contact.

Some families choose to allow foods that have PAL, but some do not. Avoiding these food products will restrict options and may not be necessary for all children with allergies. Guidance on the need to avoid products with a ‘may contain’ or other precautionary label should be discussed with parents and carers, and the child’s health professional.

It is important to communicate clearly with parents/carers, and food service providers throughout the menu planning process.

Aside from checking the labels of prepacked food for allergens, childcare settings who produce food on site are required to keep accurate recipes including a clear list of the allergens present in each dish/menu. This information should be available for parents and carers to access upon request and should be updated each time a recipe or menu is changed or updated. If food is provided by an external food service provider, you should communicate with them regularly to ensure allergen information is available and up-to-date. The food service provider may have their own special diet request procedures.

Childcare settings should take appropriate precautions to reduce the risk of contact with allergens but there is no way to ‘guarantee’ that food provided will be free of allergens. You may choose to exclude specific foods (peanuts and tree nuts for example) as a way of reducing risk. However, it is not feasible to exclude all allergens such as dairy, eggs and/or wheat without causing unreasonable dietary restrictions for other children. Decisions about food exclusions are unique to each childcare setting and the practicalities and implications of enforcing such exclusions should be considered.

! Food labels should be checked each time a product is purchased; food manufacturers can change ingredients without notice or warning.

! Check each product at the point of delivery to ensure that it is the product that was ordered; any substitutions should be checked for potential allergens.

Cross contact

For children with food allergies even a small amount of an allergen can cause an allergic reaction and potential for a longer-term impact on health. It is important for childcare settings to reduce the risk of cross contact as much as possible.

Ways you can do this include:

• Washing your hands thoroughly with warm soapy water before and after handling allergens (alcohol-based gels are not suitable for the removal of food allergen residues).
• Cleaning surfaces, utensils and equipment thoroughly and regularly using hot, soapy water, before and in between tasks where allergen containing foods have been used/prepared.
• Storing foods that contain allergens separately in clearly labelled containers, e.g. gluten free bread to avoid contact with bread containing gluten.
• Sealing opened packets appropriately or storing them in airtight, labelled containers to reduce the spread of foods that can become airborne, e.g. flour.
• Ensuring the same spoon or utensils are not used for different ingredients or dishes.
• Ensuring mealtimes are appropriately supervised so children do not share food and utensils.
• Ensuring children’s hands are cleaned thoroughly before and after eating using the prescribed hand washing procedure (alcohol-based gels are not suitable for the removal of food allergen residues).

Allergens cannot be removed or destroyed by cooking to a high temperature, so it is important that they are managed carefully. All childcare providers are required to follow correct food safety and hygiene practices. Further information on food safety and hygiene can be found in Section 5.6.

Relevant HSCS:

1.19 My care and support meets my needs and is right for me.

4.4 Coeliac disease

Coeliac disease is a common and serious autoimmune condition that can develop at any age. When someone with coeliac disease eats gluten (a protein found in wheat, barley and rye), their immune system attacks itself and causes damage to the gut. This means that their body might find it difficult to absorb nutrients from food properly. Coeliac disease is treated with a lifelong gluten-free diet.

Children with coeliac disease must strictly avoid foods containing gluten, e.g. ordinary wheat flour, bread, breakfast cereals, crackers, biscuits, pastry and pasta. Many packaged and processed foods contain gluten, e.g. some processed meats and fish, sausages and soups, and these must also be avoided.

Traces of gluten may also be found in foods where gluten is not an ingredient but where there has been cross contact of gluten containing foods. Section 4.3 provides further information on cross contact. An example of this is oats. Oats do not contain gluten but can be contaminated by other cereals during production. Some people with coeliac disease get symptoms even with gluten-free oats but this is rare.

There are many specially manufactured gluten-free foods available. These include gluten-free bread, pasta, biscuits and flour.

The following websites provide further information on coeliac disease:

NHS Inform- Coeliac disease

Coeliac UK

4.5 Diabetes

There are two main types of diabetes; type 1 and 2. It is most likely that any young children with diabetes in your care will have type 1 diabetes. This is an autoimmune condition, treated with insulin and cannot be treated or cured by diet.

If you have a child with diabetes in your care, they will need a health care plan, developed in collaboration with the child’s parents/carers and local paediatric diabetes team. This may include details on diet, carbohydrate counting and insulin treatment. It may also include emergency treatment for episodes of hypoglycaemia (low sugar). Staff may require training in the use of these treatments. Further information on training provided below.

Insulin doses may be based on the carbohydrate content of what the child is eating, so the family may need access to menus.

Children with diabetes should eat a healthy balanced diet and follow the same advice as for the rest of the population, unless advised otherwise by the child’s parents/carers. The increasingly common use of diabetes technology such as insulin pumps and continuous glucose monitoring means that children with type 1 diabetes can enjoy the same menu as their peers and should eat at the same time. Extra snacks may be required to manage their diabetes appropriately.

Local paediatric diabetes services may provide training or be able to signpost to appropriate training. The following websites provide further information on diabetes:

DigiBete – teaching videos for carers including early years providers.

Diabetes UK – a resource pack for schools which could also be used by early years providers.

JDRF (Juvenile Diabetes Research Foundation) – resources for education professionals.

4.6 Selective eating

Selective eating, which is sometimes referred to as food refusal, restricted eating or fussy eating is common typically in children aged around 18 months to 2 years. It is normal for a child who was eating a wide range of different flavours and textures to then start expressing preferences for specific foods.

Given that children are more likely to try new foods when with their peers, childcare settings offer the ideal opportunity to help children have more variety in their diet and to therefore develop healthy eating habits that can be continued at home. Equally, parents and carers know their child best and may be able to help you by advising what works in the home environment. Childcare settings should work together with parents and carers to support children who have very restricted diets.

Where parents and carers report severe and persisting selective eating, and the childcare setting can confirm this, parents and carers should be encouraged to seek advice from their health professional who may suggest reasonable modifications to meals and snacks. A special diet may be required in the most extreme cases but should be overseen and reviewed regularly by their health professional.

The following websites provide further information on selective eating:

Fussy eaters- British Dietetic Association (BDA)

Top Tips for Fussy Eating- HENRY

Food & Eating- Parent Club

4.7 Children with additional support needs and other special diets

Some children may have specific dietary needs because of physical or developmental issues, which may affect their ability to eat independently, for example difficulty with textures or swallowing. These children may need to have their food prepared in a particular way to make it easier to eat. They may need childcare settings to provide one to one support at each meal and snack time if they are unable to feed themselves.

This is an important way to meet HSCS 1.34 ‘If I need help with eating and drinking, this is carried out in a dignified way and my personal preferences are respected’. Further information on HSCS standards can be found in Section 5.

It is also important to consider children who may experience sensory issues around foods, for example, sensitivity to textures, tastes or smells, which can lead to limited preferences or aversions towards specific foods. You will need to consider these needs when planning menus and providing food, communicating with food service providers where required.

As well as modifying the foods offered, some adaptations to the eating environment could also be made, wherever possible, as a way to support the child at mealtimes, e.g. limiting noise and other distractions, having a cloth to wipe hands if required and not pressuring the child to eat.

If a child requires a special diet for a medical reason not discussed above, it is important to have written confirmation from their qualified health professional about the nature of their specific needs so that their nutritional requirements can be achieved. This information should be recorded on the child’s care plan, updated regularly and should be communicated to all practitioners and food service providers.

For children on a special diet, the parents and carers or registered dietitian should supply the childcare setting and food service provider with details of the child’s dietary needs. This will include suitable food choices for meals and snacks, foods that should be excluded or specifically included, or supplements that may be required.

4.8 Top tips for managing special dietary requirements

Responding to the needs of children with special dietary requirements requires early and effective communication with parents and carers as well as the food service provider and any relevant health professionals (in the case of food allergies or food avoidance for other medical reasons). Information on the needs of an individual child is best obtained in advance of them starting at the setting.

It is important that all practitioners understand:

• Each child’s special dietary requirements including which foods or ingredients must be avoided, and which should be included.
• Food modification for particular children.
• How to balance safety and inclusion for each child.
• Their responsibility in reducing risk, for example:
  • Preparing and serving meals and snacks.
  • Avoiding art/craft or other activities involving foods that a child is allergic to, for example, play dough or pasta (wheat/gluten), birdseed or music shakers (nuts or pulses).
  • Supervising children appropriately at mealtimes to avoid food sharing and cross contact.
  • Taking care with celebrations (e.g. birthdays, festivals or holidays) where foods are brought and shared by practitioners or parents and carers.
  • Informing parents and carers of other children of the potential risk of foods brought from home. Section 5.3 provides further information on food brought from home.
  • Encouraging children with food allergies to ask about what is in the food that is offered to them.
• Warning signs or symptoms to look out for in the case of food allergies or intolerances.
• Which children have allergy action plans in place, how to access these and follow the procedures described within them, including action to take in case of an emergency and correct administration of prescribed medication.

Childcare settings should establish a clear, written food and nutrition policy detailing procedures for managing special dietary requirements including food allergies and reducing risk within the setting.

The food and nutrition policy should be communicated to all practitioners and relevant members of the childcare setting as well as parents and carers. It is important to review and update your document regularly and have a system in place for informing temporary or bank staff of the setting’s procedures for managing special dietary requirements.

A food and nutrition policy should provide procedures to follow when planning menus for special dietary requirements. This may include, for example, what happens when a food or an ingredient in a recipe is substituted due to supply issues or a supplier makes changes to a product.

Relevant HSCS:

1.19 My care and support meets my needs and is right for me.

1.34 If I need help with eating and drinking, this is carried out in a dignified way and my personal preferences are respected.

3.15 My needs are met by the right number of people.

5.17 My environment is secure and safe.