Child and Antenatal Nutrition Manual General information ACKNOWLEDGEMENTS The Statewide Policy and Planning Directorate, Child and Community Health Division, would like to thank the many people who gave generously of their time, expertise and contribution to the 2014 edition. FEEDBACK The Child and Adolescent Community Health Policy Unit (Statewide) invites feedback from users on any aspects of this publication. Comments and suggestions may be directed to: CAN Manual Editor Child and Adolescent Community Health Policy Unit (Statewide) Telephone: (08) 9224 1625 Email: [email protected] Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 1 Child and Antenatal Nutrition Manual General information TABLE OF CONTENTS Section 1 General information Section 2 Planning for pregnancy Section 3 During pregnancy Section 4 Breastfeeding Section 5 Infant formula Section 6 Growth Section 7 Introduction to solids Section 8 Toddlers: 1 – 3 years Section 9 School-aged: 4 – 11 years Section 10 Aboriginal nutrition Section 11 Multicultural nutrition Section 12 Overweight and obesity Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 2 Child and Antenatal Nutrition Manual General information The Child and Antenatal Nutrition (CAN) Manual is a guide for community and child health professionals on various issues related to the general nutritional health and wellbeing of mothers, infants and children. The information and recommendations bring together current evidence as well as national and international guidelines to encourage consistent messages and advice along with practical support. The first edition of the CAN Manual was published in 1987 and since then, the CAN Manual has been regularly reviewed and updated. Child health professionals including dietitians, community child health nurses and policy officers have been involved in each review to ensure the information is current and practical; and the format user-friendly. Context Following the release of the National Health and Medical Research Council‟s (NHMRC) Australian Dietary Guidelines (2013)1 and Infant Feeding Guidelines (2012),2 nutritional resources used by health professionals in community and clinical practice needed updating to ensure evidence-based information and appropriate support were provided to parents. The main source of information for community health staff, including child health nurses, is the CAN Manual, last updated in 2010/2011. The CAN Manual is not only used as a reference by community health staff employed by the Western Australian Department of Health, but also other government and non-government agencies working with families. The Child Health Services Birth to School Entry Universal Contact Schedule emphasises the importance of providing nutrition information. Within this schedule, community child health nurses are encouraged to contact parents as early as possible after the birth of their baby for the purposes of supporting and establishing breastfeeding and the development of a trusting relationship with the family. Each of the scheduled contacts thereafter continues to emphasise nutrition information appropriate to the child‟s developmental stage. Consistent with the universal contact schedule, the Personal Health Record (2013) includes a „topics to discuss‟ section. This section provides prompts for parents about nutrition and other health, developmental and behavioural issues and concerns which they may like to discuss with community health professionals. Health promotion is a critical component of each contact between community health staff and parents/carers of infants and children. To assist, the CAN Manual links the nutrition practice guidelines with other relevant child and community health policies in Western Australia. Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 3 Child and Antenatal Nutrition Manual General information Rationale Maternal and child nutrition is an important priority in Australia. The maintenance of sound health throughout the life cycle is reliant on good nutrition during pregnancy and lactation, and ensuring optimal infant and child growth.1 The general health and dietary intake of pregnant and lactating women are vital to the health of infants and children. Investigations of many adult chronic diseases have identified poor maternal nutrition as a contributing factor. Children born to women whose dietary intake and health is inadequate have been shown to be at increased risk of developing abdominal obesity, diabetes, hypertension, cardiovascular disease and renal disease.3 In addition, current research indicates birthweight and growth during childhood influences subsequent disease patterns in the adult years. Ongoing efforts are required to reduce the prevalence of low birthweight babies, avoid under nutrition and the development of overweight and obesity during childhood in order to improve long term health outcomes.1,2 Expert opinion and research worldwide concur that breastfeeding provides the best nutritional start for infants. The World Health Organisation‟s 2001 World Assembly endorsed the recommendation for exclusive breastfeeding of infants until around six months of age, with the introduction of complementary feeds and continued breastfeeding thereafter.4 The Australian Infant Feeding Guidelines (2012)2 encourage health professionals to continue promoting breastfeeding as the norm, and to support mothers to overcome feeding difficulties they may encounter. Evidence suggests that supporting breastfeeding is also an important strategy for reducing overweight and obesity in children. Community health staff play a vital role as mothers may need support to establish and sustain lactation to around six months after birth. An individual‟s body weight increases about twenty-fold from birth to 18 years of age. Early childhood and adolescence show the most rapid changes in body weight consistent with periods of rapid growth. It is during these periods that children are most nutritionally vulnerable. At this time, their nutrient and energy needs in relation to their body size are greater than those of adults. The ultimate aim is for adequate nutrition and physical activity to achieve optimal growth and wellbeing.4 Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 4 Child and Antenatal Nutrition Manual General information Objectives of this manual To provide a practical, evidence-based guide for community and child health professionals on various issues related to maternal, infant and child nutrition. To link relevant nutrition practice guidelines with: “All about Me” Personal Health Record. Child health record used by community child health nurses. Community health policies, procedures and guidelines manual. To assist community and child health professionals in translating the science of nutrition into consistent, practical, evidence-based information for families and the general public. Limitations of this manual The Manual contains standardised nutrition guidelines to be used by health professionals. The information focuses on the general health and wellbeing of mothers, infants and children. Specific diseases or therapeutic treatments are generally beyond the scope of the Manual. However, some references to diet-related problems are included to enable community health staff to support specialist dietary or medical treatment and management and /or identify a need for specialist referral. This Manual: will not provide individualised dietary information will not describe the special dietary needs of women, infants and children requiring therapeutic diets. Individualised diets require comprehensive interpretation of a complex set of factors pertaining to the client and as such, are outside the scope of the general information provided. Some factors considered when designing individual diets include the client‟s socioeconomic, ethnic and religious background, eating habits, medical, surgical, biochemical history and status, motivation and barriers to change. For individual dietary information and/or therapeutic dietary management, consult or refer to a dietitian or general practitioner (GP). Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 5 Child and Antenatal Nutrition Manual General information How to use this manual Who is this manual for? This Manual is designed to meet the needs of a wide range of health professionals in community and child health services, including community health staff (child health, school health, remote area health and generalist nurses; rural practitioners; migrant/ethnic health and Aboriginal health workers), midwives, practice nurses, dietitians and GPs. For community health professionals The Community Child Health Contact Schedule section is included in this edition. It contains a table showing the list of key nutrition topics for discussion at each scheduled universal contact, as specified in relevant sections of the community health policy, procedures and guidelines manual. Format This CAN Manual is available online only and can be access on the PMH internet http://www.pmh.health.wa.gov.au/health/CAN/index.htm This Manual is divided into topic sections with a Key Points, Overview and Recommendations for Practice section at the start of each topic. Where possible, a list of useful professional references and education resources are provided at the end of each topic for further reference. Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 6 Child and Antenatal Nutrition Manual General information Community child health contact schedule Universal contact schedule The Birth to School Entry-Universal Contact Schedule is an evidence-based practice approach to community health services for parents, infants and young children. The universal contact schedule includes consultations at key developmental stages, where the child health nurse can provide information and support relevant to child development and family circumstances, as well as appropriate early detection and screening. The emphasis is on innovative and flexible service delivery to improve access for families. Table 1 shows a list of key nutrition issues that may arise at each scheduled universal contact and their corresponding sections in the CAN Manual, although nurses must be prepared to respond to parents‟ questions at any time. Targeted high-risk groups Child health professionals have an important role in identifying risks that may affect a child's wellbeing or development. Adverse physical and social factors may place families in need of additional contact and support from appropriate health and community services. These families need targeted interventions. The capacity of parents to adapt to the changing needs of the child will be determined by their personal and social context. Adverse personal factors may constrain parenting adaptability, namely disability, drug misuse, parenting age, and/or physical or mental health problems such as severe depression or anxiety. A number of factors may also affect a parent's capacity to be perceptive, responsive and flexible in their parenting approach, including poverty, food insecurity, poor neighbourhoods, inadequate housing, social isolation, relationship distress and/or domestic violence.5 Clinically, it is widely accepted that an individually focused intervention is less likely to be successful if other major contextual sources of adversity in a person's life are not also addressed.5 In addition, the issue of how the child contributes to parenting effectiveness needs to be considered. Factors that increase a child's needs include sensory impairment, disability, illness and/or behavioural and emotional problems. Contextual factors such as a violent neighbourhood, lack of appropriate play spaces, and a poor school environment can also make meeting a child's needs more difficult for some parents. Problems arise when the demands of caring for a child are so overwhelming that they exceed the parent‟s capacity.5 These families need to be targeted for additional contact and support from appropriate health and community services. Prevention programs focusing on support for parents and the provision of information on age appropriate child development, injury prevention, immunisation and nutrition may be delivered either in a group format or on an individual basis. Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 7 Child and Antenatal Nutrition Manual General information Nutrition issues for targeted groups Everyone needs nutritious food to stay healthy; however, some may find it difficult to obtain enough food and the right food important to living active and healthy lives. Some families and individuals may find themselves in situations where they are unable to afford or access food, leaving them vulnerable to food insecurity and, in turn, at risk of poor nutritional health.6 Food insecurity Food security is defined as ‘the state in which all persons obtain nutritionally adequate, culturally acceptable, safe food regularly through local non-emergency sources’6. The lack of reliable access to food may be constant, cyclical or temporary. There are many causes of food insecurity. Income, education, cooking ability, age, frailty, disability, ethnicity, remoteness and limited physical access to food, social isolation and chronic illness, are key factors influencing and affecting food choices. Causes can also be compounded, as is common for Aboriginal Australians on low incomes and living in remote communities, sometimes cut off from services, and for some individuals with disabilities. Income, education, cooking ability, age, frailty, disability, ethnicity, remoteness and limited physical access to food, social isolation and chronic illness, influence and affect food choices. Causes can also be compounded as is the case for Aboriginal Australians on low incomes and living in remote communities, sometimes cut off from services, and for individuals with disabilities.6 The health inequality and poor health status experienced by disadvantaged families is further compounded by food insecurity. The immediate effects are anxiety, hunger and lack of energy. In the longer term, there is growing evidence that people experiencing food insecurity are more likely to be overweight or obese, particularly women.7 People on low incomes also report lower consumption of fruits and vegetables, often due to difficulties in accessing, purchasing and storing.6 Good nutrition may not come easily for vulnerable and disadvantaged families. Therefore, child health professionals need to be aware that healthy eating is more than eating nutritious foods. Cultural, social and environmental factors that also determine the type and amount of food eaten need to also be recognised and addressed respectfully and appropriately. Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 8 Child and Antenatal Nutrition Manual General information Table 1: Key nutrition topics at each scheduled universal contact Scheduled Contact Key Nutrition Topics Birth to 10 Days (First Contact) Infant Feeding – Breast Exclusively/Predominantly/Complementary Attachment Feeding difficulties and solutions Expressed breastmilk Infant Feeding – Formula Correct preparation technique Appropriate volume and frequency Maternal Health Nutrition Breastfeeding support and encouragement Support agencies Infant Feeding – Breast Exclusively/Predominantly/Complementary Frequency of feeds Supply and demand Expressed breastmilk Infant Feeding – Formula Correct preparation technique Appropriate volume and frequency Maternal Health Nutrition Breastfeeding support and encouragement Support agencies Infant Feeding – Breast Exclusively/Predominantly/Complementary Frequency of feeds Changing feeding patterns Infant Feeding – Formula Correct preparation technique Appropriate volume and frequency Introduction of solids around 6 months Indicators of readiness Process of introduction Fluid intake and requirements Maternal Health Breastfeeding support and encouragement Introduction of solids Progressive introduction of textured solids Feeding difficulties and solutions Fluid intake and requirements Cup use Establishing healthy nutritious and varied diet Breastfeeding Breastfeeding to 12 months and beyond Infant Formula Use infant formula to 12 months Establishing positive family eating environments Small appetite Temporary food fads Fussy eaters Food grazing, routines and expectations Food intake and requirements Fluids Water preferred Cup use Positive family eating environments Healthy nutritious and varied diet At 6 – 8 weeks At 3 – 4 months At 8 months At 18 months At 3 – 3.5 years Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 Relevant CAN Manual Sections Breastfeeding Infant formula Growth monitoring and action Breastfeeding Infant formula Growth monitoring and action Breastfeeding Infant formula Introduction of solids Growth monitoring and action Breastfeeding Infant formula Introduction of solids Toddlers: 1-3 years Toddlers: 1-3 years General Information 9 Child and Antenatal Nutrition Manual General information Fluids (water preferred) Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 10 Child and Antenatal Nutrition Manual General information References 1. National Health and Medical Research Council. Australian Dietary Guidelines. Canberra: NHMRC, 2013. 2. National Health and Medical Research Council. Infant Feeding Guidelines. Canberra: National Health and Medical Research Council; 2012. 3. Scientific Advisory Committee on Nutrition. The influence of maternal, fetal and child nutrition on the development of chronic disease in later life. London, 2011. 4. World Health Organisation. Global Strategy on infant and young child feeding [online] 2003 [cited 2014 May 19]. Available from: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf 5. Department of Family and Community Services. Parenting Information Project Volume 1: Main report [online] 2004 [cited 2014 May 19]. Available from: http://www.parentingrc.org.au/index.php/sharing-knowledge/project-archive/3content/programs-sharing-knowledge/213-parenting-information-project 6. National Public Health Partnership. Eat Well Australia: an agenda for action for public health nutrition 2000 – 2010 [online] 2001 [cited 2014 Mar 19]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/healthpubhlth-strateg-food-nphp.htm 7. King T, Kavanagh AM, Jolley D, Turrell G, Crawford D. Weight and place: a multilevel cross-sectional survey of area-level social disadvantage and overweight/obesity in Australia. International Journal of Obesity 2006; 30(2):281-7. Date Issued: 2007 Date Reviewed: June 2014 Next Review: June 2017 NSQHS Standards: 1.7 General Information 11
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