Although clear guidelines on drinks and the use of bottles and cups for this age group were published in the 1994 COMA Report on Weaning¹, many parents still make poor choices^2,3,4. In recent years the consumption of sugary drinks and fizzy drinks has increased in toddlers as well as older children. In the last National Diet and Nutrition Survey (NDNS) of 11/2 - 41/2 yr olds, 24% children had carbonated drinks most days of the week⁵.

A study of 18 month olds in Avon, part of the ALSPAC study, indicated only 20% drank water while 7% drank fizzy drinks and 17% tea or coffee. 10% drank semi-skimmed milk and 1% skimmed milk rather than whole cows’ milk which is recommended for this age⁶.

Surveys indicate that many parents do not understand the link between consuming frequent and large quantities of sugary drinks and the risk of dental caries. A survey in Wales⁴ found mothers reported their children did not like water, but in some cases it had never been offered as the mothers didn’t drink water themselves. Some mothers regarded giving water rather than a sweet drink as ‘cruel’. In one case water in feeding bottles was seen as a sign of poverty. Milks were often not considered as an alternative to sweet drinks but were seen as food and given only at meal times and before bed.

Babies with mothers of lower education level and from lower social classes are those most likely to be put at risk of anaemia by receiving cows’ milk as their main drink before 1 year of age⁷. They are also more likely to be put to bed with a bottle containing a sugary drink^2,4. Table 1 summarises recommendations based on the Department of Health and Food Standard Agency guidelines on drinks for this age group.

Breastmilk

It is well accepted that mother’s breastmilk is the ideal and preferred drink for infants from birth for a variety of health reasons. Exclusively breastfed babies do not need extra water, even in very hot weather, as they will increase their fluid intake by demanding more frequent breastfeeds.

Infant Formula

Infant formulas, which are continually being modified and improved as research in this field advances, are the only recommended alternative to breastmilk in babies’ first year.

Composition of these formulas is constant unlike the changing nature of breastmilk and so in hot weather babies could be offered extra cooled boiled water. Whey based formulas are closer in makeup to breastmilk. Formulas higher in casein and lower in whey are traditionally marketed as suitable for hungrier babies because casein remains in the stomach longer than whey. However babies should be offered more milk if they appear dissatisfied at the end of a feed rather than being changed to a different formula.

Organic infant formula milks are made from the milk of cows on organic farms. Organic regulations allow only certain natural pesticides. The regulations governing the pesticide levels allowed in non-organic infant formula are so strict that there is now little difference between organic and non-organic infant formula.

Water

Tap water or bottled water must be boiled and cooled for babies under 6 months. This can be offered as an extra drink in very hot weather for those being formula fed. Most bottled still waters are suitable but natural mineral waters with a high sodium content (i.e. above 200mg/litre which is the upper limit for tap water) should not be used.

Once weaning onto foods has become established babies should be offered sips of water from a cup with their meals. After 6 months this does not have to be boiled first.

Follow-on milks

Follow-on milks which are suitable for infants from 6 months, as part of a weaning diet, contain slightly higher concentrations of most nutrients and significantly more iron. They were developed to provide more nutrients to growing babies during the initial weaning period and their use has been shown to reduce iron deficiency anaemia where the weaning diet is of poor nutritional quality⁸. They can also be very useful for babies over 6 months who were born prematurely and who need a higher nutrient milk.

Cows’ Milk

Whole or full fat cows’ milk can be introduced as the main drink for babies from 12 months old. At this age the contribution of milk in the diet should be reduced in favour of other foods. 350 – 600mls (12-20 oz) per day is recommended¹ and this can be partially or wholly substituted with full fat yoghurts and cheese. For toddlers who are eating a varied diet and growing well semi-skimmed milk can be introduced at 2 years if this suits the family. Continuing with whole cows’ milk beyond this age will provide more calories as well as extra Vitamins A and D.

Toddler Milks

Toddler milks are a more nutrient dense alternative to cows’ milk for those over 12 months. They can be useful for toddlers when a healthcare professional or mother is concerned that the toddler’s diet is poor for any reason.

Fruit juices

Fruit juices can be introduced after 6 months⁹ when weaning is under way. However they are acidic and contain the fruit sugar fructose and so should be well diluted, offered in a cup not a bottle and given with meals or snacks so they are drunk over a short period of time. Normal fresh fruit juices or pure juices made from fruit juice concentrates are suitable. Birth to Five⁹ recommends diluting them 1 in 10 with water. Those marketed for babies are usually made from fruit juice concentrates.

Babies weaned onto a vegetarian diet should be encouraged to use diluted high vitamin C fruit juices, such as citrus juices and blackcurrant juices, with meals as this will enhance the absorption of non-haem iron from the foods being offered.

	0-6 months	6-12 months	1-2 years	3-5 years
At feeds/meals and snacks	Breastmilk or infant formula Consider a little cooled boiled water for formula fed babies in very hot weather	Breastmilk or infant formula Consider Follow-on milk if weaning diet is not satisfactory Introduce water in a cup with meals. Diluted fruit juice in a cup with meals for vegetarian babies	Breastmilk if mother prefers to continue breastfeeding Whole cows` milk for toddlers who are eating and growing well Consider follow-on or toddler milk for preterm babies and for other toddlers whose diet is poor for any reason Water or diluted fruit juice	Whole cows` milk or semi-skimmed milk if toddler is eating and growing well Consider a toddler milk if diet is poor for any reason Water or diluted fruit juice
Between meals and snacks			Water and milk	Water and milk
Use of cups/beakers	X	Introduce a lidded cup/beaker especially for water and juices
Use of bottles		Begin to use a cup or beaker in place of a bottle and discontinue bottles around 12 months	X	X
Do not use	Cows` milk Tea & Coffee Any other type of milk not specifically formulated for an infant Sweetened and carbonated drinks	Cows` milk Tea & Coffee Any other type of milk not specifically formulated for an infant Sweetened and carbonated drinks	Drinks with sweeteners Tea & Coffee Carbonated drinks	Tea & Coffee Carbonated drinks

Fruit juice drinks and squashes

Fruit juice drinks are really sweetened, coloured drinks with about 5-10% fruit juice added. Mothers should be advised that these drinks are not pure fruit juice and are therefore very low in fruit nutrients. They will contain sugar and/or sweeteners and may contain colourings and preservatives. Like squashes the sugar and acid content make them cariogenic when drunk frequently. Large quantities of them will make toddlers feel full and they will be less likely to want to eat more nutritious food.

Fizzy drinks/Carbonated drinks

These drinks are not suitable for babies and toddlers as their acidity damages tooth enamel.

Low sugar squashes and carbonated drinks

Low sugar soft drinks whether carbonated or not are also acidic and may contain sweetners such as aspartame and saccharin which are not suitable for children under 3.

Tea and coffee

Because of the popularity of tea as a drink in Britain it is often given to toddlers and babies. As tannins in tea inhibit iron absorption it should not be offered to toddlers and babies because their requirement for iron is proportionally much higher than that of adults. Fewer toddlers are offered coffee. It also inhibits iron absorption, but to a lesser extent than tea.

Herbal teas and powdered fruit drinks

Herbal teas and powdered drinks for babies and toddlers, if sweetened, are just as damaging to teeth as other sugary drinks. Whether sweetened with glucose, sucrose, fructose, maltodextrin or fruit juice concentrate makes no difference.

Soya milks and hydrolysed milks should be used under medical supervision in certain cases of food allergies and intolerances.

How many drinks per day?

Adequate fluid is important for babies and toddlers to prevent constipation. Toddlers should be offered a drink with their meals and once between meals. This makes about 6-8 drinks per day but more may be necessary in very hot weather and when they are particularly active.

Practice points:

Parents from lower socio-economic classes are those most in need of educating on which drinks are appropriate for their babies and toddlers to prevent dental caries and iron deficiency anaemia.

Healthcare professionals should seek to understand the attitudes of each family and their barriers to offering healthy drinks to toddlers before giving advice.

Cups should be introduced from six months old and bottles discontinued at around a year. Babies and toddlers should not be left with bottles of milk or any other drink when they go to bed. All forms of sugar i.e. sucrose, glucose, fructose, maltodextrin and concentrated fruit juice can cause dental decay. Any drinks containing these should be given in a cup, never a bottle, and should not be given frequently. Toddlers should be given these drinks at a meal or snack time only when they will be drunk quickly.

References

1. Department of Health (1994) The Committee on Medical Aspects of Food Policy (COMA) Report on Weaning and the Weaning Diet Department of Health Report on Health and Social Subjects No 45, HMSO
2. Williams NJ, Whittle JG, Gatrell AC.The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young children. Br Dent J. 2002;193(11):651-4
3. Levine RS. Caries experience and bedtime consumption of sugar-sweetened food and drinks-a survey of 600 children. Community Dent Health. 2001;18(4):228-31
4. Chestnutt IG, Murdoch C, Robson KF. Parents and carers` choice of drinks for infants and toddlers, in areas of social and economic disadvantage. Community Dent Health. 2003; 20(3):139-45
5. Gregory JR, Collins DL, Davies PSW et al. (1995) National Diet and Nutrition Survey: children aged 1.5 to 4.5 years. Volume 1:Report of the diet and nutrition survey. London: HMSO
6. Northstone K, Rogers I, Emmett P et al. Drinks consumed by 18-month-old children: are current recommendations being followed? Eur J Clin Nutr. 2002; 56(3):236-44
7. de la Hunty A,Lader D, Clarke PC. What British Children are eating and drinking at age 12-18 months J. Hum. Nutr. Diet. 2000;13:83-86
8. Daly A, MacDonald A, Aukett A et al. Prevention of anaemia in inner city toddlers by an iron supplemented cows’ milk formula. Arch. Dis. Child. 1996; 75:9-16
9. Department of Health 2004 Birth to Five Your complete guide to parenthood and the first five years of your child’s life. London HMSO
10. www.eatwell.gov.uk/agesandstages/baby/weaning/ December 2004