Paediatric and Teenage Nutrition

food, feeding and nutrition

Author: Carine Henry (Page 2 of 3)

outcomes for cow's milk allergy

positive outcomes for cow’s milk allergy

18th September 2018 / / 0 Comments

Positive outcomes for cow’s milk allergy is the 4th in the 5-part blog series on Cow’s Milk Allergy in Infancy and is best read following treatment options for cow’s milk allergy.

Around 50% of infants with non-IgE Cow’s Milk Allergy tolerate milk by age 1. Positive outcomes for Cow’s Milk Allergy depend on a number of factors including the type and severity of symptoms; the length of time taken to confirm a diagnosis; and the infants ability to tolerate exposure to baked and fermented milk. Good ongoing dietary management and support, helps those positive outcomes for cow’s milk firstly by ensuring symptoms are settled and supported with a milk free diet whilst breastfeeding or with the most suitable formula. Mum and baby can then develop confidence with feeding; mum managing the learning curve of a cow’s milk free diet, and baby learning that feeding doesn’t hurt.

Active Allergy Management
Only once there are no residual symptoms for at least 3 months exposure maybe considered; firstly to small amounts of baked milk and then fermented milk or yoghurt.  Active Allergy Management involves the deliberate introduction of small amounts of milk proteins at the right time. This helps to educate the immune system and develop tolerance.  Acquiring tolerance in this way speeds up the return to a normal diet. Considerations then:

Type and severity of symptoms
Infants with severe or immediate reactions (IgE) take longer to out grow their allergy. Those infants should not consume cow’s milk products within the first year after diagnosis, although 75% can tolerate small amounts of yoghurt by age 2.   For delayed reactions (non-IgE) such as reflux – see identifying symptoms of cow’s milk allergy most infants (>50%) have outgrown their allergy by their first birthday.

Length of time taken to confirm a diagnosis
In a 2015 survey, the average length of time taken to confirm a diagnosis was 4-5 weeks and 10 GP visits.  I am now seeing infants at a much earlier stage, due mainly to increased awareness in GP’s and in families. Early intervention is the key to seeing those positive outcomes for cow’s milk allergy at an earlier stage. In general, the longer it takes to identify symptoms, and confirm a diagnosis the longer it will take to acquire tolerance.

Ability to tolerate exposure to baked and fermented cow’s milk
Exposure and tolerance to baked and fermented cow’s milk, with the use of the Milk Ladder has seen more positive outcomes for cow’s milk allergy at an earlier stage. The Milk Ladder provides evidence based stepwise reintroduction of milk products; which can usually begin around 9 months of age. The latest version is available to download from the Allergy UK website.

Next Innovative Treatments in Cow’s Milk Allergy

treatment options in cow's milk allergy

treatment options for cow’s milk allergy

6th April 2018 / / 0 Comments

Treatment options for cow’s milk allergy is the 3rd in this 5-part blog series on non-IgE Cow’s Milk Allergy in Infancy and is best read following confirming a diagnosis of cow’s milk allergy.

 

Treatment options for cow’s milk allergy in infancy depend on the severity of symptoms and whether breast, formula or combination feeding is the preferred choice for parents.  An allergy focused clinical history taken by a GP or Paediatric Dietitian, will have the key information on which the best treatment options for cow’s milk allergy can be considered for both mum and baby.

Considerations

  • Breast feeding the cow’s milk allergic infant
  • Supplementary calcium, iodine and Vitamin D for mum
  • Advantages of continuing breast feeding for mum and baby
  • Alternative formulas for the cow’s milk allergic infant
  • First line prescription formulas
  • Symptoms requiring a more specialised formula

Breast feeding the cow’s milk allergic infant
Breast feeding can safely continue in the knowledge that it is protective for the allergic infant, with many advantages.  But it’s not without it’s challenges! Strict avoidance of all cow’s milk and it products, including the small amounts hidden in foods, will resolve the symptoms.  Mum needs to follow a well-balanced but strictly cow’s milk free diet at a time when her needs for nutrition are especially high. The widely available range of milks such as soya, oat, rice and nut milks are low in nutritional value and make a poor contribution to mums’ nutritional needs.  Mum needs to be committed and knowledgeable about her own needs.  For mums whose weight is low or who struggle to eat enough, or for mums who are having difficulty coping should seek further advice if they wish to continue breast feeding.  For babies with severe atopic eczema and poor weight gain, a formula milk should be considered.

Nutrition for mum and baby
Cow’s milk (and it’s products) are the principal source of calcium and iodine in UK diets, with needs increased during pregnancy and lactation by around 50-66%. Calcium is of central importance for women’s bone health and iodine for foetal and infant brain development and function.  Vitamin D is limited in foods but essential to ensure calcium is absorbed into bone and together with calcium and iodine should be taken in supplement form.

Breastfeeding Pros for baby Pros for mum
  • Improved immune development
  • Reduced incidence of ear, gut and respiratory infections
  • Enhanced tolerance to new foods
  • Enhanced taste development, facilitating broader weaning foods
  • Development of varied Microbiome, enhancing immune development
  • Bonding with baby
  • Helpful in return to pre-pregnancy weight
  • Reduction in breast cancer risk
  • Convenience and low cost
  • Bonding with baby

Alternative formulas for the cow’s milk allergic infant
Soya or goats milk formula are not recommended as treatment options for cow’s milk allergy in infants: 50 – 66% of infants will have immune reactions similar to those in cow’s milk allergy. Broadly, two types of formula are available as treatment options for cow’s milk allergy in infancy – peptide (EHF) or amino acid (AA).   The first treatment option is an extensively hydrolysed formula (EHF), in which the proteins are hydrolysed, “digested” or  broken down into short chains called peptides. The immune system does not recognise these peptides as cow’s milk protein in 90-95% of infants with non-IgE CMA, and the EHF is well tolerated.  There are a variety of EHF types and brands available on prescription, subtely suited to different needs, and is one area of a Paediatric Dietitian’s expertise.  Current EHF formulas are available with or without lactose (the milk sugar); casein (curds) or whey based protein; first or second (follow-on) milks with added iron and calcium.  Lactose has the advantage of making the formula taste better, but may not be well tolerated in infants with delayed diagnosis. Whey based formulas tend to empty from a baby’s tummy more quickly and may help improve symptoms of reflux. Second or follow-on milks are only suited for babies over 6 months.

Symptoms requiring a more specialised formula
For infants who develop symptoms of cow’s milk allergy during exclusive breast feeding, have severe symptoms or who are symptomatic following a 2-4 week trial on an EHF, an amino acid formula (AA) is indicated.  Proteins in this type of formula are further broken down from peptide chains into individual units called amino acids and are well tolerated by almost all infants.  As an expensive option (£30 per tin) careful consideration is given to its prescription.

Next Positive Outcomes for Cow’s Milk Allergy

diagnosis for cow's milk allergy

confirming a diagnosis of cow’s milk allergy

19th March 2018 / / 0 Comments

Confirming a diagnosis of Cow’s Milk Allergy is the 2nd in this 5-part blog series about Cow’s Milk Allergy in Infancy and is best read following identifying the symptoms of cow’s milk allergy.

Common symptoms of CMA eg. loose stools, pain/colic and reflux frequently occur in babies without CMA.  This makes the diagnosis a bit tricky.  CMA is more likely when there are at least two significant problems present which impact the baby’s wellbeing, growth or feeding.  In the absence of reliable tests, the following diagnostic pathway is used by GP’s, Paediatricians and Paediatric Dietitians in order to confirm (or exclude) a diagnosis of cow’s milk allergy.

  1. An allergy focused clinical history including questions about family and individual atopy (eczema, asthma, hayfever), infants feeding and growth history, signs and symptoms focused on the gut, skin and respiratory systems, details of previous management.
  2. If the history is suggestive of Cow’s Milk Allergy, determination of whether symptoms are likely to be IgE (immediate) or non-IgE (delayed) and referral for allergy tests if IgE suspected.  The severity and timing of reactions being important. A 2-4 week trial of a strict cow’s milk exclusion diet with suitable formula, or maternal avoidance if breast feeding, with advice on supplementation of 1000mg Calcium + 10ug Vitamin D.
  3. Resolution of symptoms during the exclusion followed by obvious and confirmed relapse on re-introduction (formula or maternal consumption if breast-feeding) confirms the diagnosis.
  4. A diagnosis can only be made following a planned reintroduction of cow’s milk, which has resulted in the relapse of symptoms, mostly commonly in in 4 out of 5 infants following this diagnostic pathway.

Confirming a diagnosis of cow’s milk allergy in a timely manners and ensuring the most appropriate treatment and support is important for a variety of reasons.  For non-IgE CMA (delayed reactions) – gut symptoms resolve, pooh habits improve, tummy’s are more comfortable, eczema improves, feed volumes increase, infants are happier feeding, positive associations with feeding are made.  All of which support growth & feeding development, which in turn makes the next steps in feeding ie. weaning to solids, run much more smoothly.  Sleep is improved for all and parents anxiety is reduced – mostly!  So, just a few things then! Timely treatment also reduces risks to the baby of developing other food allergies, which are related to the presence of atopic conditions such as infant eczema.

Non-IgE Cow’s Milk Allergy is the first and most common food allergy to develop, affecting around 5% of infants in the UK, both in exclusively breast-fed and bottle-fed babies, and usually treated by the GP.  A diagnosis can be made anytime during the first year, and will depend on the severity of symptoms, other co-exisiting conditions eg. eczema and feeding or growth related difficulties.

Next Treatment options for Cow’s Milk Allergy

 

cow's milk allergy in infancy

identifying the symptoms of cow’s milk allergy

7th March 2018 / / 2 Comments

Identifying the symptoms of Cow’s Milk Allergy is the 1st part in this 5-part blog series about Cow’s Milk Allergy in Infancy.

Cow’s Milk Allergy (CMA) is an immune reaction to the proteins found in cow’s milk affecting 1 in 20 infants in the UK.  There are two distinct types of cow’s milk allergy: IgE reactions with immediate onset of symptoms and non IgE reactions with delayed onset.  In both types, symptoms range from mild-moderate to severe and persisting with potentially life-threatening reactions such as anaphylaxis. The following table will help you in identifying the symptoms of Cow’s Milk Allergy.

Delayed Onset Symptoms

Non-IgE Cow’s Milk Allergy

2 – 72 hours after milk intake

 Immediate Onset Reactions

IgE Cow’s Milk Allergy

Minutes after milk intake
Affecting formula-fed, exclusively breast fed infants or at the onset of mixed feeding/solids Affecting formula-fed infants or at the onset of mixed feeding
Gastrointestinal symptoms may be mild-moderate or severe and persisting
colic, reflux, loose, frequent stools, soft stool constipation, painful wind,  blood or mucous in nappy, food refusal, feeding aversion, poor growth vomiting, diarrhoea, colic
Skin symptoms can be mild-moderate or severe and persisting
itchy, raised red rash, atopic eczema intense itching, erythema (raised red rash), urticaria (flushing, spreading rash), flare up of atopic eczema, angioedema (facial swelling)
Respiratory symptoms are confined to IgE reactions
acute rhinitis (hayfever), conjunctivitis (swelling in and around the eyes) ANAPHYLAXIS

This blog series will focus on non-IgE CMA with delayed onset, which although less severe can be more complex and difficult to diagnose.  This is due to a number of issues: the similarity to other common conditions during infancy such as colic, reflux or loose stools and also the symptoms being mistakenly treated as lactose intolerance. Again this is due to the similarity in gut symptoms such as colic, bloating, discomfort and diarrhoea.  Unlike IgE CMA, there is no diagnostic allergy test for non IgE CMA and because reactions are delayed up to 72 hours after intake, cause and effect is not quite so clear. Lactose intolerance does not involve immune reactions, but results from lack of the digestive enzyme lactase, with malabsorption of the “milk sugar” lactose  causing discomfort and diarrhoea. A lactose free formula (which normally contains cow’ s milk protein) will resolve lactose intolerance but not Cow’s Milk Allergy,

Non IgE Cow’s Milk Allergy in infancy responds extremely well to prompt dietary treatment, with the majority of infants outgrowing their allergy within 6-12 months.  Delays in diagnosis and treatment lead to symptoms becoming severe and persistent, with feeding difficulties and growth faltering more evident.  Identifying the symptoms of Cow’s Milk Allergy early and discussing an allergy focused history with a trained GP or Paediatric Dietitian will assist making a diagnosis and accessing prompt appropriate treatment.

Next Confirming a diagnosis of Cow’s Milk Allergy.

a spoonful of sugar helps the porridge go down

26th September 2017 / / 0 Comments

I am now thinking about sugar in teaspoons; I am thinking 5 a day. Adults should be consuming a maximum of 30g added sugar per day, (and children 19-24g) so it depends on the size of your teaspoon; mine is quite big at 6g. A typical level spoonful is 4g; so is a sachet or a cube. A larger teaspoon or heaped is about 6g. Naturally occurring sugars are found in milk, whole fruits and vegetables and are not counted as added sugars. Added sugars are those added at home or by the manufacturer as well as those present in honey, fruit juices and syrups.

I want to keep added sugar within limits, know how much I have and of course I want to enjoy my food. Strangely, thinking in teaspoons of sugar helps me to think more positively about added sugar.

This nutritional calculation, comparing a luxury bowl of porridge to a typical sugar-ladden snack shows similar calories but very different amounts of added sugar. Perhaps it’s my Scottish roots, but I eat porridge quite often, especially when I need to be focused and work through the afternoon without feeling hungry.  Sounds dull and uninteresting? Ring the changes with some essential indulgence. This is my creamed porridge with raspberries recipe containing 1 teaspoon of added sugar.

   

Add 100mls water and 240mls whole milk to a small pot over the heat
Add 40g porridge oats and bring to the boil, then simmer for 5 minutes, stir occassionally
Pour into a bowl to cool; add a handful of frozen raspberries – pushing them into the hot porridge
Sprinkle 1 teaspoon Demerara sugar and let it melt
Drizzle 1 spoonful of double cream. YUMMY!


Nutrition Facts per portion
Creamed porridge with raspberries Can classic coke (330mls) and Snickers Bar (48g)
Calories 385kcals 384kcals
Protein 12g 4.5g
Total sugars 21g 33g
of which added 5g (1 teaspoon) 28g (> 5 teaspoons)
Fat 16g 13g
Calcium 300mg 47mg

You can see that all calories are not equal! There is similar calorie content but 5 times the amount of added sugar.  Total sugar in the porridge comes from naturally occurring sugars: lactose in the milk (11g) and fructose in the raspberries (5g).  More than twice the amount of protein, and lots of slow release carbohydrates help feelings of fullness for longer.  No sugar high – and no sugar slump!  With 6 times the amount of calcium at 300mg,  a 30% contribution to a teenagers daily needs for this essential  mineral. Oh yes, and it’s healthy for the skin, the digestive system and the brain; providing soluble fibre, prebiotics and slow-release energy for many hours.

 

the human microbiome – what do we know?

23rd February 2017 / / 0 Comments

The human microbiome is our own unique ecosystem, totalling all the microbes living within our body, which amount to trillions of essential, pathogenic and opportunistic microbes including bacteria, viruses and parasites. Imagine our gut as an ecosystem, designed by nature and adapted for purpose.  It makes good use of what it consumes, recycles what it can and eliminates what it doesn’t need. This ecosystem changes over time, adapting to fixed conditions including age and gender; changing conditions such as environment or diet and others such as pathogens, illness or emotions.  Recent scientific findings show that the microbiome is of critical importance in communicating and modulating the relationship with our own unique world.  Could it be the missing link between the brain, gut and immune system?  Can we use this knowledge to improve our health and wellbeing?

Development of the microbiome starts with gut exposure to amniotic fluid in the womb, through the birth canal, the immediate environment after birth and from milk feeding.  To some extent the new infant inherits its mothers microbiome, and is also strongly influenced by early feeding and diet. It has long been known that immune benefits are conferred to breast fed babies.  More specifically, breast-fed babies have less gastrointestinal infections throughout the first two years of life, and have different species of bacterial thriving in their guts. By pre-school age, children will have a microbiome resembling adults and this will continue to change throughout life. Physiological and hormonal changes during puberty, affect the microbiome as it adapts to its changing environment.

Regular antibiotic use has a profound effect on the microbiome, having longterm effects on the balance of essential and pathogenic microbes in the gut.  This altered environment can influence many aspects of wellbeing including susceptibility to infection, food intolerance, depression, obesity and gastrointestinal problems.  Refined sugar is the single most harmful dietary ingredient for our system, not only providing empty calories and consuming essential nutrients for it utilisation, but also providing food for pathogenic microbes.  This contributes to an unfavourable balance of microbes, where pathogenic ones thrive and multiple at the expense of the essential, beneficial ones.

Want to know more about microbes? http://learn.genetics.utah.edu/content/microbiome/

 

 

 

Eatwell Guide

a balanced plate for primary school children

6th October 2016 / / 0 Comments

A balanced plate, palate and healthy eating for school children means eating a wide range of foods from all of the food groups as shown in the Eatwell Guide. Children from age 5 until 11, learn about healthy eating at school as well as at home. What and how they eat at school is an important part of their learning. As children grow, their needs for key nutrients change, although calcium and iron continue to be a priority for maintaining growth and development. A healthy weight can be achieved by getting the balance between energy intake from food and spending energy in physical activity. 3 top priorities and 15 top tips for a balanced plate for primary school children:

Don’t skip breakfast

  • Eating breakfast improves concentration and behaviour during the school day
  • Start the day with a wholegrain breakfast cereal or toast with milk or natural yoghurt plus fruits or a small glass of fruit juice. A boiled or poached egg with toast is a good alternative
  • Breakfast in associated with maintaining a healthy weight and not with weight loss and helps to avoiding snacking on high sugar and fat snacks like crisps, biscuits and confectionery
  • Breakfast clubs at school can provide a healthy breakfast

Eat three meals a day; breakfast, lunch and dinner

  • A routine of three meals per day help provide the energy and nutrient needed
  • Make sure each meal includes at least one portion of fruit, vegetables or salad
  • Include starchy foods such as pasta, rice, wholegrain bread or potatoes with their skins
  • Choose a protein foods rich in the minerals iron and zinc eg. meat, chicken, fish, eggs, beans, nuts
  • Include at least 3 portions of dairy foods or alternatives as a source calcium
  • Snack sensibly and limit sugars
  • Sugar contains “empty” calories and causes dental decay. Added sugar is found in many foods like soft drinks, breakfast cereals and snacks but also occur naturally in fruit juice, smoothies and honey.

Avoid sweets and sweetened fizzy drinks

  • Swap any soft drinks for water
  • Choose lower sugar varieties of milk drinks and smoothies
  • Change to no added sugar cereals containing more whole-grains
  • Offer fruit as a snack after school when kids are hungry or a more substantial snack if doing extra sports or the evening meal is a long way off

Need further advice?  Contact Carine to make an appointment.

nutrient needs in the early years

nutrient needs in the early years

8th August 2016 / / 0 Comments

Nutrient needs in the early years are 4 – 5 times greater than for an adult.  Some nutritional knowledge is therefore essential in selecting a nutritious diet for your youngster.  Eating a range of foods from the main food groups, with three meals a day plus 2 – 3 planned snacks means that food is never far from a mum’s mind!  In a recent survey from the Infant & Toddler Forum, 73% of mums felt that their toddler wasn’t eating enough, yet childhood obesity is increasing.  Think quality NOT quantity.

Essential fats for brain growth and development
Young children need a range of healthy fats and oils for developing tissues in the brain and nervous system. Fats provide a concentrated source of energy, to help get enough calories into smaller tummies. Whole milk (4%) and dairy products should be used unless excessive weight gain is a problem. They contain more vitamins A and D needed for developing bones, muscles and the immune system. The body cannot made it’s own essential fats so depend on a dietary supply. Choose oily fish every week, nut butters, avocados, seeds and whole-grains cereals to provide those essential fats.

Getting the balance right with fibre
Too much fibre for young children can fill them up, reduce absorption of important nutrients like iron and zinc and reduce their appetite. On the other hand fibrous foods are less processed and contain their own essential nutrients; feed the good bacteria in our lower gut to maintain good gut health. Think Goldilocks! – not too much not too little, but just right! Include small portions of pulses, beans, nuts and seeds regularly.

Swap the sugars
Sugar contains “empty” calories and causes tooth decay.  Simply avoid it where possible.

Should I use salt?
Too much added salt is not suitable for young children. Most dietary salt is found in pre-packed foods, convenience foods and savoury snacks like crisps. Home cooked food is naturally lower in salt, so helps to keep salt intake lower.

Need further advice?  Contact Carine to make an appointment.

does my child need a vitamin D supplement?

8th August 2016 / / 0 Comments

metabolism of vitamin DThis is a question many parents ask me. Multivitamin and mineral supplements should not be needed as nutrient deficiencies are rare in the UK. Provided your child is eating a variety from the 5 food groups, they are unlikely to need a vitamin supplement. The exception for this is a Vitamin D supplement. Rickets, a condition where growing bones are misshapen, is caused by Vitamin D deficiency in childhood.  It was prevalent in UK children in the early 1900’s, and is being seen increasingly in the UK again.  The reasons are multi-factorial and include less time playing outside in the sunshine, the use of sun-block because of worries about skin cancer and declining oily fish consumption.  Oily fish is the only significant dietary source of Vitamin D. More than 90% of our Vitamin D needs are met by the action of UV sun rays on the skin. Recent guidance on the need for a Vitamin D supplement from Public Health England (PHE) following a SACN review of the evidence on Vitamin D and Health says

“Children aged 1 to 4 years should have a daily 10 microgram vitamin D supplement. PHE recommends that babies are exclusively breastfed until around 6 months of age. As a precaution, all babies under 1 year should have a daily 8.5 to 10 microgram vitamin D supplement to ensure they get enough. Children who have more than 500ml of infant formula a day do not need any additional vitamin D as formula is already fortified.”

Sure Start vitamins containing Vitamin D are available for all children under 4.  Pregnant and breast feeding mums should also remember to take a Vitamin D supplement containing a minimum of 10ug daily.

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