Food Justice

Maverick Life

What to feed children: The nutritional standard

By Catherine Del Monte 13 September 2021

Image: Supplied

Research has shown the importance of childhood nutrition in setting them up for a healthy future. But what exactly does an adequate nutritional childhood diet look like?

Catherine Del Monte

Gilbert Tshitaudzi, a nutrition specialist for Unicef South Africa, and dietitian Aziwe Booi stress the importance of exclusively breastfeeding a child for the first six months of their life. 

“A healthy diet for a child should start with breastfeeding because it provides essential irreplaceable nutrition for a child’s growth and development,” says Tshitaudzi.

Apart from laying a firm foundation for a child’s growth and development, according to the Demographic and Health Surveys (DHS) Programme, breastfeeding exclusively for the first six months of a child’s life also helps to “prevent infections, such as diarrhoea and respiratory illnesses”.

“After breastfeeding exclusively for the first six months, mothers can introduce nutritionally adequate and safe complementary foods whilst continuing breastfeeding their children for up to two years old or beyond,” says Tshitaudzi.

This is where the benchmark of the minimum acceptable diet comes in – a nutritional standard created to ensure a child’s growth and development. 

As set out by the DHS, the minimum acceptable diet encompasses appropriate milk feeds, diet diversity, which is “eating from at least four of the seven standard food groups to ensure that macro- and micronutrient requirements are met”, and minimum meal frequency (how often a child should be eating) to ensure a child’s energy requirements are met. 

The seven standard food groups are: grains, roots and tubers; legumes and nuts; dairy products (milk, yoghurt, cheese); flesh foods (chicken, fish, liver/organ meat, red meat); eggs; vitamin A-rich fruits; and other fruits and vegetables.

According to the DHS: “For children aged six to eight months, the minimum meal frequency is met when a breastfed child receives solid, semisolid, or soft foods at least twice a day. For children aged nine to 23 months, this increases to at least three times a day.

“For children aged six to 23 months who are not breastfed (formula-fed), a minimum meal frequency is reached when solid, semisolid, or soft foods are received at least four times a day.”

Tshitaudzi says that, “From six months the child needs to gradually be introduced to iron-rich foods (dried beans, egg, minced meat, boneless fish, chicken or chicken livers, ground mopane worms) which must be cooked and mashed to make them soft and easy for the child to swallow, and caregivers can start by providing one to two teaspoons, twice a day.” 

He adds that these amounts, together with the frequency of feeds, should be gradually increased as the child grows, in order to meet nutritional requirements.

Booi breaks down these amounts further: after the initial start of one to two teaspoons twice a day, an increase to two to three tablespoons of a variety of foods can be made. 

“The main aim should be to incorporate variety at every mealtime and age so that they benefit from all the different food groups.”

“Meals should eventually add up to about half a cup of soft food that gradually increases to about two to three feeds a day,” says Booi, noting the importance of gradually increasing textures of foods as well, “to prevent choking hazards or a child developing an exclusive preference for soft textures”. 

The aim is to keep increasing food intake gradually while keeping breastmilk intake approximately the same, or 600ml of milk for formula-fed babies, to ensure the child receives all the nutrients they need.

From nine to 11 months old, Booi says, portion sizes should be approximately half a cup of food three to four times a day with the inclusion of a healthy snack like mashed fruit and yoghurt. 

“The texture can gradually change; you can start to chop up soft food into small pieces instead of mashing it completely,” she notes. “The pincer grasp is a developmental milestone that occurs during this time which means your children may even become more skilled at feeding themselves with their fingers.” 

Between the ages of one and two, the dietitian says that children can consume about three quarters to one cup of food three to four times a day, plus one to two snacks between meals.

Booi says that the average portion sizes for one to five-year-olds should be: four to six (a maximum of 10) servings of whole-grain carbs; two to five servings of protein; two to four servings of milk and dairy; and one to two servings of fat.

“These are all dependent on your child’s individual needs, but the main aim should be to incorporate variety at every mealtime and age so that they benefit from all the different food groups,” says Booi.

“It is a good idea to keep track of the first food introductory processes so that it is easy to track which foods may have resulted in any reactions or allergies.”

Booi adds that allowing babies to self-feed with spoons filled with food during dinner times is a good way for children to become familiar with new foods. 

“Babies are highly intelligent and learn quickly from repetition and modelling the behaviour of those around them, so the earlier you try to introduce this during dinner times the more skilled they’ll become at self-feeding,” says Booi.

She says it is a good idea to keep track of the first food introductory processes so as to be aware of which foods may have resulted in any reactions or allergies. 

Booi emphasises the importance of practising “responsive feeding” throughout the feeding process, and explains that responsive feeding refers to taking note of a child’s “hunger” or “fullness” through cues they may express verbally or nonverbally. 

“Hunger and fullness cues are crucial for all children to learn so that as they grow they’re able to know when they’re hungry or full. This helps them develop healthier eating habits,” she says.

Common signs of hunger expressed by children aged six to 12 months include reaching for or pointing at food; coos, smiles and gazes; and excitement when food is presented to them. Common signs of fullness expressed by children aged six to 12 months include shaking the head to indicate “no more food”; pushing food away; keeping the mouth tightly closed; and covering the food with their hands.

Introduce fruit and vegetables from the get-go

Booi also recommends including vegetables first among the initial foods introduced at six months of age as a way to encourage vegetable consumption early on. 

“The aim is also to be persistent in the introduction of all vegetables as there is no guarantee that a toddler would enjoy any first foods immediately, because if we are honest there are many foods we didn’t enjoy initially and have grown to enjoy, even as adults,” she says.

“Sneaking vegetables into children’s favourite meals is a quick and easy way to make foods more nutritious without the little ones even knowing.”

Booi points out that, because children are master mimics and will take cues from the behaviour of those closest to them, like their parents, they are more likely to eat foods that the rest of the family is also eating during dedicated mealtimes.

“Sneaking vegetables into children’s favourite meals is a quick and easy way to make foods more nutritious without the little ones even knowing,” says Booi. Creative ways to do this include grating carrots into spaghetti bolognese or adding spinach or green beans into stews. 

“Frozen fruit, smoothies or homemade yoghurt and fruit lollies are a fun, delicious snack that can be given to children (once it isn’t a choking hazard, of course) to make it feel more like a dessert,” she adds.

Booi implores caregivers not to lose hope if children present an unwillingness to try different foods at first. 

“It can take up to 10 tries to get a child to enjoy or tolerate certain foods. You can always try again in a couple of days or mix those certain foods with ones they’ve enjoyed. Sometimes, even squeezing in some breast milk can help ease them into the new flavours.” 

Booi recommends adding the following five food items to a child’s diet:

Beans and fortified wholewheat cereals: “Children’s iron needs to be increased after six months, the best way being through the child’s diet. so iron-rich food sources are very important. Any common gut-related concerns that surround bean intake can usually be resolved by soaking any beans before preparation to reduce stomach discomfort, AKA gassiness,” she says.

Colourful food: There should always be an orange, red and yellow fruit and vegetable in the trolley as these food items are a rich source of vitamin A, which is important for the maintenance of a child’s immune system and a natural defence against illness and infection. These foods include peppers, oranges, carrots and naartjies. “Green vegetables like spinach are also highly nutritious and affordable. They contain a variety of nutrients including fibre, protein (3g per serving) iron, B vitamins and vitamin C, calcium, potassium and magnesium, to name a few,” Booi explains.

Next, Booi recommends zinc-rich foods to support immune health and wound-healing. “Zinc becomes quite useful if your little one has a nappy rash.” Zinc can come from animal sources such as yoghurt, chicken or eggs, as well as plant sources such as whole grains like oats and beans.

No trolley is complete without fruit. Booi says that fruit is packed with vitamins, minerals and fibre. “Remember to be cautious of fruit that may be a choking hazard. Try to cut into smaller portions or mash or peel where necessary to reduce this as much as possible.” 

Lastly, she recommends incorporating yoghurt and dairy products as “a balanced snack”. Dairy products contain protein, fat and carbohydrates and are also sources of calcium and vitamin D, which Booi says are “important for bone and immune health, amongst other health benefits”.

Pulling the sweet tooth 

Now that we have got a clear picture of the childhood nutritional standard/minimum acceptable diet, the next dietary issue to tackle is processed sugar. 

Booi says that children develop a liking for sweet tastes because breast milk and amniotic fluid are sweet. “Children tend to latch on to sweet tastes quicker as they are amongst the most familiar.”

“Creating a reward pattern for children can often be a challenge in future as you do not want them to get used to being rewarded for something they should be doing, like eating fruits and vegetables.”

Booi does not advocate the complete removal of processed sugar from a child’s diet. The aim, she says, is two-fold: to allow processed sugars in small amounts and to prioritise the intake of nutrient-rich food items (never letting the child’s desire for sweet things limit this intake).

“We need to allow children to be children, meaning they should be able to enjoy an occasional sweet food of choice. It is important to not completely demonise these foods early on as it may cause a child to develop an unhealthy relationship with food in future.”

Booi recommends reducing processed sugar intake by ensuring that these kinds of foods are reserved for after nutrient-rich foods. “This way they may even consume them in smaller amounts since they’ve consumed a satisfying meal.” 

Better still, Booi recommends sweet alternatives that are high in fibre and nutrient-rich, such as fresh fruit, which also provides vitamins and minerals.

“Whole fruit should, however, always be prioritised in children as they contain fibre, which is what makes fruit more satisfying. Fruit also provides fruit sugars (known as fructose) in less concentrated amounts and fruit even comes in its own recyclable packaging in the form of peels,” says Booi.

For parents who want to use honey to sweeten food, Booi says children can only consume honey once they are older than one year as their immune systems are not mature enough to process some of the bacteria that may be present in honey and could lead to a type of food poisoning called infant botulism. 

She also cautions parents against rewarding their children for eating vegetables with their favourite foods. 

“Creating a reward pattern for children can often be a challenge in future as you do not want them to get used to being rewarded for something they should be doing, like eating fruits and vegetables.” 

Booi warns against hidden sugars and liquid calories in fruit juices and fizzy drinks. In order to moderate a child’s fruit juice intake and to encourage them to drink more water, Booi recommends diluting fruit juice little bits at a time until there is hardly any fruit juice in their cup. 

“The good old diluted juice trick! This is important as we don’t realise how concentrated the fruit sugars are in juices,” she says. 

“Fortunately, there are even juice boxes that are already diluted, which is useful for parents who want to add a fun juice box into their children’s lunchbox without adding too many concentrated sugars or fruit sugars. 

“Encouragement, patience and sneaking in vegetables where possible is crucial to ensure picky eaters are getting in as much nutrients as possible.” 

Tshitaudzi says that there is  an urgent need to improve the desirability and, most importantly, the accessibility of nutrient-rich foods in families.

While reductions in prices of these foods and demand creation could help increase the nutrient consumption of young children in some households, Tshitaudzi adds that mechanisms such as these are unlikely to help the bottom 20-35% of households, which are extremely resource-constrained. 

“In the short term, cash transfers will be critical for these low-spending food-insecure households, and in the long term, raising incomes and/or promoting homestead production will also be necessary,” says Tshitaudzi.

“Improving the nutrition knowledge and practices of caregivers may contribute in ensuring that the cash transfers received through the social protection system are well spent on healthy food items that can provide the adequate amount of nutrients needed for a child’s growth.” DM/ML

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  • Does this dietician have any children of her own? Supremely good luck if you can keep a baby born at 4kg off solids and breast milk only until 6 months
    Didn’t happen. 3 – 4 months is about the limit.

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