Paediatric and Teenage Nutrition

food, feeding and nutrition

Category: Children

good sources of calcium

what’s the difference between lactose intolerance and cow’s milk allergy?

26th November 2019 / / 1 Comment

Many people are confused about the difference between lactose intolerance and cow’s milk allergy. Misunderstood as same condition; the terms lactose intolerance and cow’s milk allergy are used interchangeably and incorrectly.  Most likely due to the similarity of symptoms such as bloating, wind and diarrhoea;  both being related to drinking milk and alleviated by avoiding it. When I say milk – I mean mammalian milks such as cow’s (including infant formula) goats, sheep and human milk.  So, here is the main difference:  Cow’s Milk Allergy is an immune system response to milk protein, which drives a spectrum of symptoms affecting the skin as well as the tummy.  In the more severe IgE allergic reactions, the mouth, throat and breathing are affected. Lactose intolerance is not an allergy but a physical response due to lack of digestive enzyme lactase required to digest the milk sugar lactose. This blog will give an overview of symptoms, causes and dietary management of lactose intolerance providing further links on products and nutritional information.

Lactose Intolerance
Is a normal response to the presence of undigested lactose (milk sugar) in the large intestine. When lactose digestion fails in the small intestine the lactose sugar travels onto the large intestine where bacterial fermentation, responsible for the characteristic bloating, discomfort and wind, takes place. In the presence of large amounts of lactose, water and salts are drawn into the large bowel (by osmosis) causing increased water volume, urgency to go to the toilet and explosive stools. Lactose is found in milk and dairy products like soft cheese and yoghurts.  Hard cheeses have naturally low levels of lactose, as do products like butter, margarine and double cream.  Adults and older children with established lactose intolerance can typically eat these foods without any problem. Those small amounts of lactose provide food for the friendly lactobacillus bacteria which normal live in the large bowel.

What are the causes of lactose intolerance?
Lactose intolerance itself does not cause damage to the small intestine; rather it’s the result of tissue damage to the intestinal lining which affects lactase enzyme production.  A temporary condition in infants and young children, it will resolve as the gut cells turnover and repair themselves. Lactase enzyme decreases progressively with age with around 70% of the world’s population with limited lactase activity.  Persistent lactose intolerance is uncommon in infants and young children, due to their high milk intake, which maintains enzyme production. Teenagers however may not regain their lactase activity following small intestinal damage or serious infection.  The most common causes of lactose intolerance include:

  • Gastro-intestinal infection with characteristic diarrhoea and vomiting
  • Allergic inflammation, especially with unresolved non-IgE Cow’s Milk Allergy
  • Small bowel bacterial overgrowth eg. in older children, teens

Products and differences in dietary management 
It’s important to understand that the nutritional composition of milk alternatives make them unsuitable as drinks for infants and toddlers, but can be a useful addition to solids, when a nutritious fluid is needed to blend or mix.  When selecting a milk alternative, always choose one fortified with calcium. Lactose free milks and cheeses made from cow’s milk contain cow’s milk protein, making them unsuitable for those with cow’s milk allergy.  Vegan cheeses, whilst lactose and cow’s milk protein free have poor nutritional value and are not fortified with any calcium.  A low lactose diet to treat lactose intolerance is usually followed for between 2 and 6 weeks (depending on severity of symptoms) and a cow’s milk protein exclusion for CMA for at least 6 months. Use this guidance on reintroducing lactose back into the diet  if you had lactose intolerance but do seek further guidance for Cow’s Milk Allergy in Infancy if feeding is difficult and you are unsure about next steps.

alternative milks

reintroducing lactose back into the diet

30th October 2019 / / 0 Comments

Following a 2 – 6 week low lactose diet to treat lactose intolerance, your child should now be well on their way to recovery from symptoms.  Reintroducing lactose back into the diet in a controlled way is the next step. Starting with low lactose foods, then adding in medium and, once you’re satisfied all is being tolerated, finally adding in high lactose-containing foods. Use the guidance below on lactose content of dairy foods to assist you, taking about 2-4 weeks, gradually increasing, will do several things:

  • stimulate production of lactase, the small intestinal digestive enzyme that digests lactose
  • help establish and then increase the amount of dietary lactose that is tolerated
  • assist in the build up and return of normal lactase production in the small intestine

Re-establishing tolerance to lactose
Re-establishing tolerance to lactose varies from child-to-child, depending on age, habitual diet and degree of severity. Because infants and young children are more dependent on a high milk diet, the lactase enzyme returns more readily and lactose intolerance is usually temporary.  Resumption of a normal diet is somewhere between 2-6 weeks for most infants and children. Referred to as secondary lactose intolerance this is often the result of nasty gut bugs like rotavirus, or can be secondary to small intestinal damage caused by untreated cow’s milk protein allergy or coeliac disease. Individuals including older children and teens may develop primary lactose intolerance or a permanent reduction in lactase enzyme, more typically affecting non-caucasian children and those with a habitually low milk/no milk intake following a similar route via infection of small intestinal irritation.  Amounts of 2 – 4g lactose per day are usually well tolerated despite the lack of lactase enzyme.  Instead lactose is digested by the lactobacillus bacteria, naturally residing in the large intestine.

Other points worth noting about lactose intolerance and reintroduction

Special care with infants
Formula fed babies with lactose intolerance, need a lactose free formula. Lactose intolerance may also occur in breast-fed babies but is less common; only in very rare congenital primary lactase deficiency would there be a need to stop breast feeding and use a lactose free formula. What is important, is to correctly identify if cow’s milk allergy are the cause of the symptoms, to ensure that infants get the right dietary treatment. Products in the shops vary enormously in nutritional composition, and are not suitable to drink because of poor nutritional quality.

Lactose content of dairy foods

Very Low Lactose

< 2g per portion

 Medium Lactose

2-4g per portion

 High Lactose

4-6g per portion
The foods in this group contain very low amounts of lactose and are tolerated by most people with lactose intolerance.  If consuming these foods does not give any symptoms, try medium lactose foods per portion. Continue to introduce lactose containing foods, including foods with medium lactose. If symptoms return, go back to the previous tolerated stage for 2 weeks and try again. In addition to very low and medium lactose content foods, continue to introduce lactose-containing foods, including one portion from the high lactose category.
Cheese 1oz
Most hard cheeses have very small amounts of lactose and are unusually well tolerated. Eg. cheddar, red leicester, caerphilly, stilton, parmasan Cheese spread, cottage cheese, soft cheeses eg. ricotta, marscapone, dolchelate Cheese spread, quark

 
Yoghurts & fromage-frais 60g 125g Larger portion
Greek yoghurt, Goat’s yogurt, all yoghurts and fromage-frais Yoghurts and fromage-frais, Low fat fruit yoghurts, Organic whole milk yoghurt Natural whole or fruit yoghurt, Low fat natural yoghurt, Diet/low calorie yoghurts
Dairy desserts & creams 2oz 4 – 6oz Larger portion
Half fat cream, Single, Double, Whipping, Clotted cream, UHT Spray Cream, Fresh Cheese Cake 1 scoop ice cream, Frozen cheesecake, Trifle with cream, 1 chocolate mousse 2 scoops ice cream, 10mls Angel Delight, 150g tinned rice pudding, 100mls Custard
Hidden milk
1 x small slice cake, 4 chocolate digestives, 1 chocolate coated biscuit eg. 2 finger kit-kat, 100g egg custard tart 1 milk chocolate bar, 125mls whole milk, 70mls evaporated milk, 1 tblsp skimmed milk powder, 40mls condensed milk
good sources of calcium

good sources of calcium

2nd October 2019 / / 1 Comment

Infants and children need good sources of calcium in their diets on a daily basis. Calcium absorption in the gut is variable and ranges from 25-50%, increasing when intake is low and reducing when intake is high. Plenty of foods rich in calcium are especially important throughout infancy to support the rapid bone growth and bone mineralisation that occurs at this time. The uptake of calcium by bones is then regulated by Vitamin D, with Vitamin D deficiency limiting bone mineralisation even in the presence of adequate calcium.  Growth spurts during infancy and childhood, from a surge in growth hormone provides a boost to calcium absorption, which further strengthens bone mineralisation. Absorption of calcium from breast milk is very efficient at around 66% and from formula milk around 40%.   For all infants and young children offer them calcium rich foods every day.

  • Dairy products like milk, cheese and yoghurt are the UK’s best sources of calcium for infants and young children
  • Calcium is also found in tinned fish, nut butters, tahini or sesame seed pulp, hummus, figs, dates, and green vegetables
  • White wheat flour is fortified in the UK with 120mg Calcium per 100g
  • Water in areas of hard water like Cambridge contains 120mg calcium per litre
  • For all children with cow’s milk allergy, take care to offer calcium enriched products, checking sources of other valuable nutrients such as protein, iodine, Vitamin D as well as overall calories
  • Prolonged poor calcium intake will lead to brittle bones that break more easily, both in childhood and in later adulthood
  • Exercise and weight bearing activity will also strengthen bone
  • Have a quick check on recommended intakes to check if your child is getting enough calcium
  • Download the portions of calcium rich foods below
  • Infants and young children need a Vitamin D supplement containing a minimum of 10ug daily until 5 years and thereafter for a minimum of the 6 Winter/Spring months to maintain good levels

Recommended Intakes

  • Daily calcium needs during infancy are 525mg 
  • 5-600mls formula provides the majority of calcium during infancy
  • Breast fed infants depend on mum’s diet, and a calcium and vitamin D is advisable for mum
  • Daily calcium needs during early years are 350-450mg; provided by 3-4 portions of calcium rich foods
  • Daily calcium needs during primary school are 450-700mg; provided by 4-5 portions of calcium rich foods
  • For all children with cow’s milk allergy, take care to offer calcium enriched products, checking sources of other valuable nutrients such as protein, iodine, Vitamin D as well as overall calories.

 

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.

portion sizes for your toddler

19th July 2016 / / 0 Comments

How confident do you feel about portion sizes for your toddler?  In a recent survey from the Infant & Toddler Form, 73% of mums felt that they their toddlers were not eating enough.  Toddlers appetites vary depending on how they feel, what’s on offer, how tired they are  Some days there is no feeding them.  Fussy eating and food refusal during the toddler years is a great cause for concern with parents, but it is a normal part of childhood development. Toddlers can be be tricky feeders at mealtimes, with food refusal gaining attention and often resulting in a battle of wills.  Use this portion size guide to help guide you.

Can giving toddlers large portions cause excess weight gain and obesity?
Large portion sizes for toddler meals are linked to obesity development says another recent survey.  There is however no single cause for obesity, just as there is no single correct portion size for toddler. Meal times are good opportunities to eat nutritious food, and portion sizes of nutritious food should not be limited.  Foods high in fats and sugars, deep fried and battered should be kept to a minimum, as these are very high in calories and do contribute to obesity if eaten regularly. But, it’s often the food eaten outside of mealtimes that is high in calories with low nutritional value.  For all you worried mum’s out there, its good to know that nutrient deficiencies are rare in the UK, and children who are eating a variety of foods from the 5 food groups will not need a vitamin supplement.

Need further advice?  Contact Carine to book an appointment.

 

foods rich in iron

8th June 2016 / / 0 Comments

All children need regular sources of iron-rich food, especially during later infancy, toddlerhood, teenage girls and for those following vegetarian or vegan diets.  Iron availability from food is variable, and absorption in the intestine is limited to around 15-20%.  Iron absorption depends on a number of changing factors: the iron status within the body, general health.  Iron absorption generally decreases with age. The availability of iron within food is known as bioavailability.  We depend on dietary iron to make haemoglobin, the oxygen-carrying molecule found in our red blood cells. Delivery of oxygen to the body, muscle and brain is its most important role in the body, but also for brain development, concentration and stamina. Vegan infants, children and teenage girls will need an iron supplement; but it’s also good to be aware of the natural rich sources,   foods fortified with iron and factor affecting its absorption.

Maximise iron intake, absorption and bioavailability with these top tips
  • Avoid giving milk with a meal as the high calcium content of milk reduces iron absorption
  • Do include fruits and vegetables with each meal; the Vitamin C content increases iron absorption
  • Avoid giving children tea; the tannins in tea bind iron and reduce its absorption
  • Foods containing haem-iron and from animal sources like red meat and eggs are absorbed well
  • Foods containing non-haem-iron from plant sources like cereals, fruits, nuts, pulses and vegetables are less well absorbed
  • Eating meat 1 -2 x a week, 3-6 eggs per week, regular beans, pulses, nuts, fruits, cereals and vegetables will meet the needs of most children
  • Other plant sources of iron include apricots, blackcurrants, figs, prunes, cocoa, dark green leafy vegetables, lentils, edamame beans, kidney beans, soya mince, TVP,  tofu, cashew nuts, peanuts, tahini, sesame seeds, pumpkin seeds, oats, wholegrains, quinoa, fortified cereals eg. ready brek, weetabix
    • Please note that because tofu is also rich in calcium, the absorption is limited to around 5-10%
  • Vegetarian and vegan school children generally have lower iron status but do get sufficient iron from beans, pulses, soya mince, nuts, nutritional yeast with iron, tofu, fruits, cereals and vegetables – vitamin C intake is a valuable addition to enhance absorption for this group
  • Toddlers can reduce the risk of iron deficiency by having water with main meals instead of milk

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