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Vitamin supplements for children: advice to nurses

Sarah Jean-Marie
BSc(Hons) PGDip
Senior Dietitian
Sure Start
Stamford Hill
London

Early nutrition is important for optimum growth and development; good weaning practices introduce a wide range of foods that help to prevent nutrition deficiencies, such as rickets and iron-deficiency anaemia. Establishing a healthy diet early on can help to reduce the risk of dental decay, childhood obesity and, in the long term, chronic adult diseases such as coronary heart disease.

The first six months
Breast milk or infant formula provides all the nutrients that a baby requires up until the age of six months.(1) Babies who continue to drink breast milk or babies drinking less than 500ml of infant formula are recommended to take vitamin drops to ensure that they receive extra vitamin D.(2)
The World Health Organization recommends that weaning starts at six months,(3) as in the first few months of life babies grow rapidly and their iron store is quickly depleted, so by the age of six months it is essential that iron-rich foods, such as red meat, fortified breakfast cereals, eggs, dark green vegetables and pulses such as chickpeas, lentils and beans are included in the diet. The absorption of nonanimal sources of iron can be improved by foods rich in vitamin C, such as fruit and vegetables, or very diluted pure unsweetened fruit juice (one part of juice diluted in 10 parts of water). The variety and texture of foods introduced can be increased quite quickly, and it is important that babies are eating food from the four main food groups (see Table 1). A varied, balanced diet will provide a range of nutrients.

[[NIP28_table1_17]]
 
Up to 12 months
By 12 months babies should have three meals a day and two or three nutritious snacks such as yoghurt, cheese cubes, toast, fruit and vegetables. All babies over the age of 12 months should be given vitamin supplements until the age of five years old, unless it can be shown that their diets are diverse and plentiful (see Table 2).(2)

[[NIP28_table2_17]]
 
In practice this can be very difficult to assess accurately. Only a very detailed diet history, which is analysed by dietitians, can indicate with some degree of accuracy whether the diet is adequate. Children's diets tend to vary quite widely, especially with the limited food intake during teething, colds and other minor illnesses. In the most recent National Diet and Nutrition Survey around 12% of children aged between 18 and 30 months had iron-deficiency anaemia with a haemoglobin level below 110g/l.(3) The survey also found that the average intake of iron and calcium was significantly lower in children from manual groups than those in nonmanual groups.(4)
 
Nutrition deficiency in vulnerable groups
Higher levels of iron-deficiency anaemia have been found in Asian children(5) and in African Caribbean children.(6) A study in Birmingham in a group of children aged 18 months found 19% of those with a white European background were anaemic, and 27% of those with an Asian background and 29% of those with an African Caribbean background were anaemic.(7)
According to the National Diet and Nutrition Survey almost 100% of the children aged between 1½ and 4½ years had vitamin D intakes lower than the recommended amount.(4) It is assumed that their requirements will be met through sunlight exposure rather than diet alone.(8) However, this is a serious issue for children from families on a low income, and communities where religion or culture requires the skin to be covered up, such as Muslims and Orthodox Jews. It is also a concern for people with dark skins from Asia and West Africa, and African Caribbean people, who require more exposure to sunlight to manufacture enough vitamin D.(9)

Pregnancy and breastfeeding
Studies show that vitamin D deficiency is more common in pregnant women in the Asian community.(10) The most recent Infant Feeding Survey shows that 95% of black women, 87% of Asian women and 67% of white women breastfeed their babies from birth.(11) It is known that breastfed babies are more likely to have low levels of vitamin D due to the low concentration in breast milk. It is therefore not surprising that there is a relatively high percentage of children in the Asian community who have low serum 1,25-dihydroxyvitamin D levels.(12) Very few studies have been carried out in the African Caribbean community in the UK. However, in America the incidence of rickets within African American children is also on the increase.(13)
With the decline in the uptake of vitamin drops there has also been a resurgence in vitamin D deficiency rickets in the UK.(9) It is therefore essential for all health workers to promote nutrition and vitamin supplements in line with the recommendations (See Table 2).
It is crucial to highlight the importance of good nutrition and vitamin supplements to pregnant women and women who are breastfeeding.
The uptake of vitamin supplements has fallen in the last two decades. In 1990, 30% of women who were breastfeeding babies aged between 8 and 9 months offered vitamin drops to their baby - this fell to 18% in 1995, and 10% in 2000.(11)
Two-thirds of the mothers giving vitamin drops gave Department of Health children's vitamin drops, which they either bought prescribed or were given free of charge from the child health clinic through the Welfare Food Scheme.
Until 2003, children's vitamin drops were available at a low cost from the child health clinic, and for families on income support or jobseeker's allowance. Unfortunately these vitamins are no longer available at clinics. The DH is now working on a Healthy Start initiative, replacing the Welfare Food Scheme, which will be available in the future.(14)
In the meantime, only families in receipt of income support can receive Abidec from clinics free of charge; other families can purchase vitamins from the chemist or supermarket.

Which supplements?
There are various types of vitamin supplements available. Suitable supplements include Abidec, Dalivit, and Minadex, as well as brands from supermarket and chemist's own brands, which may be cheaper (see Table 3). It is important to check that the supplement is appropriate for the baby's age and that the correct dosage is given.

[[NIP28_table3_18]]

A study of primary schoolchildren showed that cod liver oil was given to 25% of children in African Caribbean communities in the UK.(15) Some brands are no longer suitable for children under the age of five years because the level of dioxins exceeds the current safety limit for that age group. Parents should check whether the supplements they use are appropriate for children under 5 years old.

Conclusion
The promotion of nutrition is an important role for all healthcare workers working with pregnant women, women who are breastfeeding, and young children. It is also crucial that they receive appropriate advice on supplements, especially for families that are at particular risk, such as those on a low income or from minority ethnic groups.

References

  1. NHS Direct. Babies, weaning. Available from URL: http://www.nhsdirect.nhs.uk/articles/article.aspx?printPage=1&articleId=664
  2. Department of Health. Weaning and the weaning diet: report of the Working Group on the Weaning Diet of the Committee on Medical Aspects of Food Policy Report on Health and Social Subjects 45. London: HMSO; 1994.
  3. World Health Organization. Nutritional anaemias. WHO technical report series no. 503. Geneva: WHO; 1972.
  4. Gregory J, et al. National diet and nutrition survey: children aged 1½ to 4½ years. Volume 1: report of the diet and nutrition survey. London: HMSO; 1995.
  5. Lawson M, Thomas M. Iron status of Asian children aged two years living in England. Arch Dis Child 1998;78:420-6.
  6. James J. Preventing iron deficiency in pre-school children by implementing an educational and screening programme in an inner city practice. BMJ 1989;299:838-41.
  7. Childs F, et al. Dietary education and iron deficiency anaemia in the inner city. Arch Dis Child 1997;76:144-7.
  8. Department of Health. Scientific review of the Welfare Food Scheme. Report of the Panel on Child and Maternal Nutrition of the Committee on Medical Aspects of Food and Nutrition Policy. Report on health and social subjects 51. London: TSO; 2002.
  9. Ladhani S, Srinivasan L, Buchanan C, Algrove J. Presentation of vitamin D deficiency. Arch Dis Child 2004;89: 781-4.
  10. Brooke, et al. Vitamin D supplements in pregnant Asian women: effects on calcium status and foetal growth. BMJ 1980;280:751-75
  11. Hamlyn, B, et al. Infant feeding 2000: a survey Conducted on behalf of the Department of Health, the Scottish Executive, the National Assembly for Wales and the Department of Health, Social Services and Public Safety in Northern Ireland. London: TSO; 2002.
  12. Lawson M, Thomas M. Vitamin D concentrations in Asian children aged two years living in England: population survey. BMJ 1999;318:28.
  13. Kreiter S, et al. Nutritional rickets in African American breastfed babies. J Pediatr 2000;137(2):153-7.
  14. Department of Health. Healthy start: a new Welfare Food Scheme. Available from URL: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Materna...
  15. Bristow, et al. The use of nutritional supplements by 4-12 year olds in England and Scotland. Eur J Clin Nutr 1997;51:366-9.

Resources
Department of Health
W:www.dh.gov.uk

Food Standards Agency
W:www.food.gov.uk

British Dietetic Association
W:www.bda.uk.com

Sure Start
W:www.surestart.gov.uk