By: Dr. Hilary Jones
December 16, 2016
Rome was not built in a day. Nor of course is a healthy human baby. The moment of conception itself might magically and randomly confer that mixture of parental genes which the baby inherits, but it’s future potential in terms of physical growth and intellectual development is also determined by a host of environmental influences, not least of which is nutrition both prenatally and thereafter.
During the 38-week gestation period key nutrients are transferred to the baby via the placenta, which are crucial to the health of the developing foetus. But if maternal nutrient levels are low even before conception and if infant nutrition postnatal is less than optimal, the consequences can be just as far-reaching and serious as foetal exposure to environmental toxins such as alcohol and nicotine.
The window of opportunity to ensure optimal nutrition is never clearer or more transparent than it is in the six months before conception and up until the child’s second birthday. Yet even now this vital message is clouded and confounded by controversial, but widely circulated reports such as that published recently in the British Drug and Therapeutics Bulletin – concluding that all vitamin and mineral supplements in pregnancy other than folic acid and Vitamin D are largely a waste of money. 
As a general practitioner and father of five children myself, I am very aware of the passionate desire of all responsible parents to do the very best they can to ensure optimal health for their children. So which nutrients do I consider especially important for infants and toddlers and which supplements do I currently recommend to parents based on the available evidence and the research that has impressed me most?
Assuming a healthy and balanced maternal diet, yet still acknowledging the deficiencies in nutrient concentrations of so many readily available modern food products and the pressures of “busy lifestyles” that can negatively impinge on healthy food choices, there can be little doubt that lack of iron, iodine, folic acid, vitamin B12 and calcium, among other essentials, can lead to delays in a baby’s learning and language development and motor skills. This can also result in lower IQ and an increased risk of future behavioural problems.
The provision of folic acid in a daily dose of 400 mcg for most women and 5 mg daily for women whose babies are considered to be at a higher risk of neural tube defects is a given. A developing baby also needs iodine to make thyroid hormones, which are essential for brain development. The baby’s mother, who is likely to be iron-deficient even in affluent and developed countries like in the US and UK, needs iron and B12 to produce the red blood cells, which will determine how much oxygen reaches the baby’s body and brain. She will also benefit from extra vitamin D as deficiency is widespread and research has shown that children born to mothers with low vitamin D levels are twice as likely to develop severe language problems at school.  Vitamin D is also important later for the absorption of calcium from food, which ensures strong teeth and bones and guards against rickets, once seen as a Victorian disease consigned to history but now is resurgent.
In terms of neurodevelopment the fastest and most significant changes are seen in the last trimester of pregnancy and the first year of life. The central nervous system begins to develop by the fifth week of pregnancy and the neural tube should close by the sixth week, which is why folate is so vital early on. Thereafter, the fetal brain undergoes rapid development and expansion with 260 percent growth in the final trimester and a further 175 percent till the age of one year. Another 18 percent of growth occurs during the baby’s second year, but even after that there is continued adaptation and organization of synaptic communications as the brain grows a further 21 percent from the age of two through to adulthood.
This rapidly growing brain, composed of 60 percent fat, demands nourishment and in particular supplies of DHA (docosahexaenoic acid) one of the long-chain omega-3 fatty acids – one of the most important components required for brain maturation and eye health. DHA accumulates in fetal brain and nerve tissue, while in the eye it comprises 30 to 65 percent of the cell membrane fatty acids of rods and cones in the retina and 50 percent of the weight of each retina). Due to its polyunsaturated chemical structure, DHA promotes speedier communication between nerve cells via the synapses and may also facilitate permanent neuronal connections at a critical time of life that can never be relived.
Babies whose diets contain high levels of essential fats have demonstrated advantages in terms of fetal development and more recent studies have shown that this is also true of infants born to mothers whose diets contain copious amounts of DHA themselves. The attention spans of these infants during the first six months of life was two months ahead of what otherwise might have been expected. [3,4,5]
Yet while the role of DHA quite rightly attracts so much current attention, the need for ARA (arachidonic acid) omega-6 should not be underestimated. Important for the development of cells in the brain, muscles, nerves and liver cells, ARA is also vital for immune system support and the prevention of eczema, and has been associated with accelerated reading and spelling skills and a higher IQ. DHA and ARA always work together and are found together naturally in breast milk.
How can parents ensure their children consume nutrient-dense foods given that food refusal on their part, teething, illness, tiredness, the beginning of childcare, and children’s parties can all interfere with the best intentions?
Between the ages of one and three years, toddlers gain an amazing 40 percent in height and weight growing faster than at any other time of their life. During these two years a child has significant development of the brain, liver, heart and other organs. Bread, rice, pasta, potatoes or other starchy foods should be eaten with each meal together with a variety of fruits and vegetables.
Carotenoids and vitamins A and C may be lacking in toddlers and children’s diets especially if they are selective eaters and not enjoying a varied diet. They are needed however to promote healthy skin, good vision in dim light, an efficient immune system, and the ability to absorb dietary iron. 
In addition, toddlers should have three servings of milk a day, including cheese or yogurt, and two or three servings of fish, eggs, nuts or beans with only small amounts of the food and drink that contain high levels of fat and sugar. Diets like this should give any active, growing toddler the essential nutrients they need at this time in their life for growth and development.
I encourage parents to prepare more home-cooking from scratch and to try not to rely too much on pre-prepared foods designed for adults, which are often very rich in salt and sugar. Chocolate and sweets should be kept to a minimum as occasional treats, and the same applies to chips and fizzy drinks. It is important to encourage children to eat lots of leafy green vegetables and fruit by starting them at a young age and reintroducing the food if they don’t seem to like them at first. Parents are often surprised to find that after six to eight attempts their children will get used to the different tastes and textures and acquire a taste for the new food.
Perseverance is worthwhile because healthy toddler nutrition means they will maximize their potential for growth and development, an opportunity that if lost at this age will never come again.
Toddlers have very different nutritional needs than older children and adults. For example, they need 4.7 times the amount of iron per kilo body weight compared to an adult, 2.8 times the amount of energy, 2.9 times the amount of calcium and 4.4 times the amount of vitamin C. 
Hopefully, they would achieve this through their diet but my recommendations for supplementation are in line with those of the National Health Service and the Scientific Advisory Committee on Nutrition – children aged six months to five years should receive supplements of vitamins A, C and D at daily doses of approximately 233 mcg vitamin A, 20 mg vitamin C and 7.5 mcg vitamin D3. 
Breast-feeding is the gold standard for infant nutrition For children who are breastfed from birth to the age of one, a daily vitamin D supplement of 8.5 mcg to 10 mcg is recommended to ensure sufficient amounts, the higher dose being continued until the age of four. . Children consuming more than 500 mls of infant formula do not require such supplements because formula milks are already fortified. 
In summary, in an ideal world, all the key nutrients to optimize infant and toddler growth and development would be provided by a healthy and varied diet, unhindered by environmental hazards and undiluted by modern farming food processing practices. But, unfortunately, few of us live in this ideal world. All infants need an adequate and regular supply of all the necessary food groups in the correct proportions, loaded as they should be with all the minerals and vitamins needed, but especially folate and vitamin D. There is now a wealth of evidence supporting the optimal intake of DHA for pregnant and lactating mothers, DHA and ARA for infants and toddlers, whether it is via diet, breast milk or enriched formula milk.
1. Vitamin supplementation in pregnancy DTB dtb.2016.7.0414. Published Online First: 11 July 2016 doi:10.1136/dtb.2016.7.0414.
2. Hart PH, Lucas RM, Walsh JP, Zosky GR, Whitehouse AJ, Zhu K, Allen KL, Kusel MM, Anderson D, Mountain JA. Vitamin D in Fetal Development: Findings from a Birth Cohort Study. American Academy of Paediatrics December 2014.
3. Colombo J, Kannass KN, Shaddy DJ, Kundurthi S, Maikranz JM, Anderson CJ, Blaga OM, Carlson SE. Maternal DHA and the Development of Attention in Infancy and Toddlerhood. Child Dev. 2004 Jul-Aug;75(4):1254-67.
4. Innis SM. Dietary (N-3) Fatty Acids and Brain Development. J Nutr. 2007 Apr;137(4):855-9.
5. Uauy R, Hoffman DR, Peirano P, Birch DG, Birch EE. Essential Fatty Acids in Visual and Brain Development. Lipids. 2001 Sep;36(9):885-95.
6. Hadley KB, Ryan AS, Forsyth S, Gautier S, Salem N. The Essentiality of Arachidonic Acid in Infant Development. Nutrients 2016, 8(4), 216; doi:10.3390/nu8040216
7. Scientific Advisory Committee on Nutrition (SACN) growth standards: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/339317/SACN_Dietary_Reference_Values_for_Energy
8. Haskell, M.J. and K.H Brown. Maternal Vitamins A Nutriture and the Vitamin A Content of Human Milk. Biol Neoplasia. 1999 Jul;4(3):243-57.
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