Paediatric Nutrition

supporting wellbeing with nutrition education

Tag: vitamin D

nutritional composition of milk alternatives

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 for cow’s milk allergy

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.


  • 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

does my child need a vitamin D supplement?

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.

calcium and vitamin D in teens

The calcium and vitamin D combination is one of the most important vitamin and mineral duos for teenage nutrition. All teens need a good supply of calcium as their bones increase in density long after they have stopped growing in length. Vitamin D plays its part by regulating the absorption of calcium from the gut. Functioning similarly to a hormone, vitamin D receives information about how much bone is needed and determines how much calcium to deliver to the skeleton to make bone.  This happens for existing bone, making it stronger and denser with the additional calcium, and also for new bone as existing bones lengthen during pubertal growth spurts.

Dietary sources of vitamin D only contribute about 5% of overall needs; the rest being manufactured on the skin’s surface by the action of UV light from the sun.  Vitamin D is then absorbed through the skin, stored in the liver, and then converted into an active form of Vitamin D by the kidney, ready for action in the gut.  

Boys generally need more calcium than girls and are also more likely to have lower circulating levels of vitamin D. Calcium needs for girls are around 800mg and boys around 1000mg. Habitual lower intakes of calcium cause the intestine to up-regulate its absorption, provided there is enough vitamin D, and so calcium is only half the picture to promote strong bones.  In the UK , where the sunlight is low for at least half the year, the general population is at risk of vitamin D deficiency.  A supplement of 25ug/micrograms (or 1000 international units) of Vitamin D for 6 months of the year – during late autumn/winter/early-spring – helps to ensure bones continue to mineralise during this super-growth period. Teens who eat a poorly planned vegan diet may consider a calcium and vitamin D supplement.

Calcium needs can be met by 4 – 5 servings of dairy products each day.  For kids who don’t eat dairy, fortified soya products, nuts and seeds are good choices.  For well-rounded nutrition, a mix of different types of calcium rich foods is best.  

Good Sources of Calcium

Portion               Food                                            Calcium (mg)
200mls cow’s milk 230
200mls soya milk 240
150g natural yoghurt 300
150g fruit yoghurt 240
30g cheddar cheese 200
30g soya cheese 125
2 tinned pilchards 330
4 tinned sardines 460
120g tinned salmon 105
1 tsp tahini (sesame seeds) 135
30g almonds 65
10 apricots 75
1 dried fig 50
90g spinach 145
3 tbls baked beans 70
portion broccoli 35
portion spring greens 65
1 slice white bread 30
1 slice wholemeal bread 20

Source “The Composition of Foods” 5th Ed; McCance & Widdowson; Royal Society of Chemistry