Paediatric and Teenage Nutrition

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Tag: paediatric dietitian

nutritional composition of milk alternatives

25th September 2019 / / 0 Comments

If you have a child who has lactose intolerance or cow’s milk allergy, chances are you need to think about the nutritional composition of milk alternatives. Cow’s milk and its products are good sources of calcium and trace elements like iodine in the UK diet.  As someone who takes nutrition seriously, a Paediatric Dietitian and mother of 3 growing teenagers, I would like to point out that the nutritional composition of milk alternatives available in our shops is shockingly poor.  It does not serve consumers well, has insufficient nutrition for infants, children or teens, and for those who depend on the nutrients milk would normally provide.  The missing nutrients and their physiological roles are as follows:

  • calcium – for growth and maintenance of strong bones, blood clotting
  • iodine – for neurological development during pregnancy, control of metabolism, thyroid function
  • Vitamin B2 – for healthy skin, eyes and nervous system, releasing energy from food
  • protein – for growth and repair of all body tissues, immune function
  • Vitamin B12 – assists in maturing red blood cells, absorption of iron
  • lactose – the milk sugar – food for the beneficial lactobacillus genus of bacteria, maintenance of a healthy intestinal microbiota

Exciting range of nut milks
I was quite excited to see such an explosion of nut milks now routinely available; and on researching this recently, felt somewhat aggrieved to see such poor nutritional composition.  Nuts are one of nature’s most incredibly nutritious foods – high in calories, protein, essential fats, minerals like zinc, calcium, iron and magnesium as well as B vitamins. They are also (currently) fairly conflict-free and sustainable. There are not many foods you can say that about! Unfortunately none – and yes I do actually mean NONE – of that goodness is retained in the resultant, washed out and expensive product marketed as milk.  Some have no calcium, no protein, no minerals no vitamins, and poor calories. Mil for mil they are 7 times the price.

Compare the nutritional composition of milk alternatives in the chart below, and take care to ensure that you choose ones with higher calories and protein for young children, ensuring they are fortified with calcium, and where possible Vitamin D and other vitamins.

Type of Milk Calories Protein Calcium Vitamin D Extras
Whole Cow’s Milk 69 3.3 120 Low Wide range of nutrients
Cow’s Milk formula 66 1.3 65 1.2 Full range of nutrients
Mature Breast Milk 67 1.3 35* Varies Wide range of nutrients
Goats Milk 70 2.8 120 Low Wide range of nutrients
Arla Lactose Free Milk 56 3.3 120 Low Wide range of nutrients
KoKo unsweetened 16 0.2 120 0.75 Nothing
Oatly Original 46 1.0 120 1.5 Vitamins
Innocent Hazelnut Milk 72 1.0 0 0 Nothing
Innocent Almond Milk 37 1.4 0 0 Nothing
Alpro Soya Original 42 3.3 120 0.75 Vitamins
Alpro Cashew Milk 23 0.5 120 0.75 Vitamins
Alpro Soya Growing-Up 1-3 64 2.5 120 1.5 Iodine, Vitamins
Rice Dream plus calcium 50 0.1 120 0.75 Not for <5years
  • absorption of calcium from breast milk is extremely efficient, but infants needs for calcium from 6-12 months through are high.  Check out  good sources of calcium if weaning your cow’s milk allergic infant.
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

 

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