PAEDIATRIC
WEANING AN INFANT WITH COW’S MILK PROTEIN ALLERGY - Part 2 Cow’s milk protein allergy (CMPA) is the most common food allergy in babies and young children and the management of CMPA is an ever-evolving landscape. In Part 2 of this article, Paula takes a look at complementary feeding and the introduction of allergenic foods, highlighting micronutrient inadequacy and its management. There are no official UK guidelines for weaning an infant with CMPA. Weaning should commence when a baby is showing all the signs of developmental readiness, which is usually around six months (but not before 17 weeks) of age. Signs of developmental readiness include: • the baby can maintain a sitting position and can hold its head steady; • the baby can pick up food and navigate it to its mouth; • the baby can swallow food (look for loss of the tongue thrust reflex). Introducing solids to a baby who has cow’s milk allergy (CMA) should be the same as for a non-allergic baby, except avoiding all sources of cow’s milk and dairy products. The Food Allergy Specialist Group (FASG) of the BDA recommends starting with green vegetables and root vegetables, potatoes
and rice, as well as iron-rich foods such as chicken, meat and pulses, from six months of age (as iron stores start to run low from six months of age for full-term babies). INTRODUCTION OF ALLERGENIC FOODS
Common allergenic foods (such as egg, soya, wheat, peanuts* and other nuts*, sesame seeds*, mustard seeds*, celery, fish and shellfish), should not be avoided once a baby is six months old, as long as the baby is not allergic to these foods. Current advice is to introduce all common allergenic foods that a baby is not already allergic to, and which are part of a family’s usual diet, between 6-12 months of age (FASG BDA). *as ground nuts, nut butters, or seed butters for babies and young children. A sensible and practical approach is to introduce each allergenic food one at a time earlier on in the day, so that the
Table 1: Products available on prescription**
Extensively hydrolysed formulas
Amino acid formulas Soya formula
Brand
Manufacturer
Aptamil Pepti 1 & 2
Nutricia
Nutramigen 1 & 2 with LGG
Mead Johnson (part of RB)
Aptamil Pepti Junior
Nutricia
Similac Alimentum
Abbott
Pregestimil Lipil
Mead Johnson (part of RB)
SMA Althera
Nestlé Health Science
Nutramigen Puramino
Mead Johnson (part of RB)
Neocate range
Nutricia
SMA Alfamino
Nestlé Health Science
SMA Wysoy
Nestlé Health Science
Paula Hallam RD, PG Cert (Paed Diet) Specialist Paediatric Dietitian Paula is a Specialist Paediatric Dietitian and owner of Tiny Tots Nutrition Ltd. She helps families of babies and children with many nutritional concerns, such as fussy eating, iron deficiency anaemia, constipation, growth faltering and food allergies. She also facilitates weaning workshops for new mums.
REFERENCES Please visit: https://www. nhdmag.com/ references.html
**For more on appropriate formulas and prescriptions, see Part 1 of Paula’s article in the October issue of NHD. www.NHDmag.com November 2019 - Issue 149
21
COW’S MILK ALLERGY
DOESN’T ALWAYS END AT ONE YEAR
TRUST NEOCATE JUNIOR TO SUPPORT HIS NEXT STEP
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Neocate Junior Aged 1 - 10 years The unique Amino Acid-based Formula for children with Cow’s Milk Allergy over one year of age. Best tasting†
Well tolerated‡
Flexible concentration
Excellent compliance‡
Visit: nutriciaproducts.co.uk/samples This information is intended for Healthcare Professionals only. Neocate Junior is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options including breastfeeding. *Product can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. † Data on file, May 2016 & January 2017 ‡ Clinical data on file, May 2016 Accurate at time of publication, November 2019. Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ
Table 2: Calcium – UK recommended intake at different ages Age
Calcium per day (mg)
0-12 months
525
1-3 years
350
4-6 years
450
7-10 years
550
11-14 years
800
Breastfeeding mum
1250
infant can be observed for an allergic reaction. Some sources also recommend starting with a very small amount of the allergenic food and to give increasing amounts over three days to observe for any possible reactions. Once introduced, and if the food is tolerated, an allergenic food should continue to be included in the infant’s diet at least once or twice per week to maintain tolerance to that food. More detailed information about infant feeding and allergy prevention is available here: www.bsaci.org/about/early-feeding-guidance. A NOTE ABOUT ECZEMA AND ‘HIGH RISK’ INFANTS
If an infant has a history of severe eczema, they are at higher risk of developing other food allergies, particularly if the eczema appeared within the first few months of life and is persistent and severe, despite treatment with topical steroids and emollients. If this is the case, parents/carers may need more specific advice from a healthcare professional about the timing of introduction of allergenic foods. A skin prick test or specific IgE blood test may be recommended first before introducing egg and peanuts. It is advisable to refer these infants to an allergy clinic early for an assessment and appropriate advice. MICRONUTRIENT ADEQUACY OF DAIRY-FREE DIETS
Cow’s milk and dairy products are an important source of energy and protein, as well as calcium, iodine, phosphorus, riboflavin, vitamin B12 and vitamin A.1 When considering non-dairy alternative food and drinks for infants and children with CMPA, these micronutrients need to be considered.
Current UK guidelines for the diagnosis and management of CMA recommend the use of a suitable hypoallergenic infant formula until two years of age for infants and children with CMPA.2 Meyer et al have supported this recommendation in a prospective observational study in 2014,3 where they looked at the adequacy of micronutrient intake in 105 children aged four weeks to 16 years of age, diagnosed with food protein induced gastrointestinal allergy. They assessed the 54 children <2 years of age separately and found that 74% of those not taking a hydrolysed formula (HF) had deficient micronutrient intakes, compared with 17% of those taking a HF. It should be noted that there was no control group in this study and the group under two years of age not taking an HF consisted of only seven children, compared to 47 children who were taking an HF. This discrepancy is due to the fact that an HF is recommended until two years of age in UK national guidelines.2 Calcium As dairy products are the principal source of calcium, a paediatric dietitian should assess the calcium intake of each infant and child with CMPA and appropriate advice given. Good sources of non-dairy calcium include nuts (ground nuts/nut butters for infants), fish with soft edible bones, tofu, pulses, seeds and calcium-fortified cereals2 (see Table 2). A study by Ambroszkiewicz et al in 2014,4 reported that children with CMPA showed some changes in biochemical bone metabolism markers and they concluded that calcium and vitamin D status should be monitored and dietary intake assessed for children on elimination diets. www.NHDmag.com November 2019 - Issue 149
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THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies
The importance of palatability when choosing an extensively hydrolysed formula for the dietary management of cows’ milk allergy in formula fed infants TASTE PREFERENCES Clinical guidelines recognise palatability as a key factor in EHF choice1–3 Infants may be prescribed their first EHF after taste preferences have developed4,5
SUPPORTING GROWTH AND DEVELOPMENT Adequate consumption of EHF is paramount to achieve nutritional requirements8,9
PRESCRIPTION ADHERENCE Bitter EHFs are often strongly rejected after 4 months of age2 Parents often report that their child refuses EHF due to unpleasant taste6
IMPROVING COMPLIANCE In a newly published study, most HCPs agree that a palatable EHF could lead to non-rejection and more content infants and families7
SUPPORTING HEALTHCARE OUTCOMES Most HCPs agree that a palatable EHF could lead to reduced repeat visits, and decreased wastage and healthcare costs7
Aptamil Pepti is the UK’s most palatable EHF In a newly published study a panel of 100 dietitians and GPs ranked Aptamil Pepti as the most palatable EHF formula7
References: 1. Venter C, et al. Clin Transl Allergy 2013;3(1):23. 2. Luyt D, et al. Clin Exp Allergy 2014;44(5):642–672. 3. Walsh J, et al. Br J Gen Pract 2014;64(618):48–49. 4. Sladkevicius E, et al. J Med Econ 2010;13(1):119–128. 5. Mennella JA, et al. Am J Clin Nutr 2011;93(5):1019–1024. 6. Vandenplas Y, et al. Eur J Pediatr 2014;173(9):1209-1216. 7. Maslin K, et al. Pediatr Allergy Immunol 2018;29(8):857–862. 8. Maslin K, et al. Clin Transl Allergy 2016;6:20. 9. Flammarion S, et al. Pediatr Allergy Immunol 2011;22(2):161–165.
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is only suitable for babies over 6 months as part of a mixed diet. 19-071. Date of prep: October 2019. © Danone Nutricia Early Life Nutrition 2019
PAEDIATRIC Table 3: Non-dairy sources of calcium Product Calcium-fortified products Hypoallergenic infant formula, eg, Nutramigen with LGG, Aptamil Pepti 1, Alimentum, Neocate LCP, Neocate Syneo, Nutramigen Puramino, SMA Alfamino Hypoallergenic follow-on formula (from six months of age), eg, Nutramigen 2, Aptamil Pepti 2, Neocate Junior (only from 1 year +) Wysoy (soya infant formula) Calcium-enriched milk alternatives, eg, soya, oat, nut, coconut ‘Extra’ calcium-fortified milk alternatives, eg, Califia Almond, Koko coconut super milk Calcium-fortified cheddar cheese alternatives, eg, Koko cheddar Tesco free-from cheddar Calcium-fortified soft cheese alternatives Koko cream cheese Tesco free-from soft cheese Calcium-fortified soya or coconut yoghurt, desserts, eg, Alpro, Oatly crème fraiche, supermarket own brands Calcium-fortified hot oat cereal, eg, Ready Brek, supermarket own brands Calcium-fortified cereals, eg, Rice Krispies, Cheerios, Alphabites multigrain cereal Calcium-fortified breads Hovis Best of Both Kingsmill 50/50 Vitamin Boost Soya bean curd (tofu) – ONLY if set with calcium chloride (E509), or calcium sulphate (E516) - not Nigari Non-fortified products Sardines (with soft bones) Pilchards (with soft bones) Tinned salmon (with soft bones)
Quantity
Calcium (mg)
100ml
47-90
100ml
60-95
100ml
67
100ml
120
100ml
170
30g 30g
220 45
30g 30g
60 45
100g
96-160
15g (1 tbsp dry cereal)
200
30g
136-174
1 slice 1 slice
191 150
60g
200
½ tin (60g)
260
60g
150
60g
250
White bread
1 slice
50
Wholemeal bread
1 slice
27
Pitta bread/chapatti
65g
60
Orange
1 medium
75
Broccoli
2 spears (85g)
34
Okra
5 okra fingers
120
Kale
20g
30
(Credit: Adapted from BDA Food Allergy Specialist Group - Cow’s milk free diet for infants and children 2019)
Please note: Some foods, such as spinach, beans, dried fruits, seeds and nuts, also contain calcium, but it is not absorbed very well, as they contain phytates or oxalates which decrease the absorption of calcium. They are still nutritious foods to include, but should not be relied upon as the main source of calcium in the diet.
Vitamin D Lower vitamin D levels have been reported in children with CMPA, especially those who are exclusively or predominantly breastfed.5 The current UK Department of Health and Social Care guidelines state that all children under the age of five years, except those receiving 500ml or www.NHDmag.com November 2019 - Issue 149
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PAEDIATRIC Table 4: Iodine intake – WHO recommendations Age
Iodine/day (μg)
0-5 years
90
6-12 years
120
Adults and children over 12 years
150
Pregnancy
250
Breastfeeding mums
250
more of infant formula, should receive a vitamin D supplement of 10 micrograms per day all year round. Pregnant and breastfeeding women should also take a vitamin D supplement of 10 micrograms per day.6 Iodine Cow’s milk and dairy products are a significant source of iodine and iodine deficiency has been described in children under two years of age with CMPA.7 This study reported a high prevalence of iodine deficiency in children with CMPA, which was particularly pronounced in exclusively breastfed infants. It is important that the diets of infants and breastfeeding mothers avoiding dairy products, contain other iodine rich foods such as white fish. If the infant (or breastfeeding mum) is also allergic to fish, then an iodine supplement should be considered. Table 4 shows how much iodine is needed for each age group, according to the WHO. Many calcium-fortified non-dairy alternatives to cow’s milk are now also fortified with iodine (as well as calcium and vitamins) and these can be an additional useful source of iodine in dairy-free diets. Examples of plant-based dairy alternative drinks that are fortified with iodine (as well as calcium and vitamins) include: • Alpro soya growing up drink 1-3 years+ • Koko ‘super’ coconut drink • ASDA oat-based drink • All M&S plant-based drinks are fortified with iodine (as well as calcium and vitamins) • Oatly are due to start enriching their oat milk range with iodine later in 2019 at a level of 22.5 micrograms iodine per 100ml See the BDA fact sheet on iodine for further information at: www.bda.uk.com/foodfacts/ Iodine.pdf. 26
www.NHDmag.com November 2019 - Issue 149
REINTRODUCTION OF COW’S MILK PROTEIN
There is a tendency for all types of CMA to resolve during childhood, but how rapidly this occurs is highly variable and, therefore, the timing and appropriateness of milk reintroduction should be individually assessed.2 There is no ideal time for testing for development of tolerance, but it is generally accepted that infants with a proven CMPA should remain on a cow’s milk proteinfree diet until 9-12 months of age, or for at least six months (after diagnosis) before attempting to reintroduce cow’s milk into their diets.8 CMPA resolution rates have been reported to vary from 19% to 97% depending on the country and whether the CMPA was IgE-mediated or non-IgE-mediated.9 Non-IgE-mediated allergy is reported to resolve quicker than IgE-mediated allergy.10 Clinical and laboratory indices can both be used to guide reintroduction.2 Clinical indices associated with persistence of CMPA include a history of severe reactions, the presence of other food allergies, asthma, rhinitis and a SPT wheal size >5mm at diagnosis.10-12 As a child develops oral tolerance to cow’s milk protein, a reduction in sIgE and SPT wheal size are seen over time.2,12 Attempts have been made to quantify by how much specific cow’s milk IgE would need to decrease before oral tolerance is seen.12-14 However, an exact percentage decrease cannot be quantified and it can only be said that a ‘substantial reduction’ in sIgE levels over time is associated with the development of clinical tolerance.2 Children who outgrow their CMA become tolerant to baked milk before fresh milk, due to the fact that baking reduces the allergenicity of the protein, particularly whey proteins.2,8 The ‘milk ladder’ has been developed for the stepwise introduction of baked milk products.8,15 Infants with IgE-mediated CMPA may require a supervised food challenge of cow’s milk protein in hospital, depending on the severity of their reactions and if they develop asthma or not.2 CONCLUSION
Weaning an infant with CMPA is not simple, but it is possible to ensure a nutritionally adequate intake with some careful adjustments to the diet and the use of calcium-fortified alternatives. Consideration should also be given to other micronutrients, such as vitamin D and iodine.
Neocate Syneo Help rebalance gut microbiota dysbiosis in infants with CMA with
NEOCATE SYNEO
1,2,5
THE ONLY AAF WITH PRE- AND PROBIOTICS* clinically proven to bring the gut microbiota closer to that of healthy breastfed infants1,5
Neocate: Fast and effective resolution of CMA symptoms
1-4
This information is intended for Healthcare Professionals only. Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions where an amino acid based formula is recommended. It must be used under medical supervision after consideration of all feeding options, including breastfeeding. †Product can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. *Accurate at time of publication, November 2019 Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend CMA: Cow’s Milk Allergy AAF: Amino Acid-based Formula References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686 2. Burks W. et al. Pediatr Allergy Immunol 2015;26:316-322 3. De Boissieu D. et al. J Pediatr 1997; 131(5):744-747 4. Vanderhoof JA. et al. J Pediatr 1997; 131 (5):741-744 5. Fox et al. Clin Tranl Allergy. 2019;9:5 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ
www.neocate.co.uk If you would like to order a product sample to be delivered directly to a patient†, please visit www.nutriciaproducts.com/samples