Complementary Feeding Complementary Feeding in Children with Food in Children with Food

HypersensitivityHypersensitivity

Jo CainesJo Caines

Paediatric Specialist DietitianPaediatric Specialist Dietitian

Introduction of SolidsIntroduction of Solids

Complementary feeding – all Complementary feeding – all solids and liquid foods other solids and liquid foods other that breast milk of infant that breast milk of infant formulaformula

Exclusive breastfeeding for the Exclusive breastfeeding for the first 6 months of an infant’s life first 6 months of an infant’s life (Department of Health 2003)(Department of Health 2003)

Infant feeding survey (2005) Infant feeding survey (2005) Only 49% parents wait until 17 Only 49% parents wait until 17 weeks to introduce solidsweeks to introduce solids

Weaning RecommendationsWeaning Recommendations Exclusive breastfeeding for 26 weeks is desirableExclusive breastfeeding for 26 weeks is desirable Complementary feeding should not be introduced Complementary feeding should not be introduced

before 17 weeks and not later than 26 weeksbefore 17 weeks and not later than 26 weeks No convincing evidence that avoidance or No convincing evidence that avoidance or

delayed introduction of potentially allergenic delayed introduction of potentially allergenic foods beyond 4-6 months reduces allergiesfoods beyond 4-6 months reduces allergies

ESPGHAN 2008ESPGHAN 2008

? Delaying exposure to high risk foods increases ? Delaying exposure to high risk foods increases the risk of allergythe risk of allergy

Introduction of Allergenic FoodsIntroduction of Allergenic Foods

Most common food Most common food allergens in children:allergens in children:

Cow’s milk, egg, peanutsCow’s milk, egg, peanuts

(wheat / soy / fish)(wheat / soy / fish) No guidelines as to how No guidelines as to how

these foods should be these foods should be introduced in children with introduced in children with known food allergy except known food allergy except for peanuts to be delayed for peanuts to be delayed until 3 years (DoH)until 3 years (DoH)

LEAP studyLEAP study

Practical Weaning AdvicePractical Weaning Advice

4 – 6 months4 – 6 months Smooth pureeSmooth puree Dairy, egg, soy, wheat, fish and nut freeDairy, egg, soy, wheat, fish and nut free Appropriate initial weaning foodsAppropriate initial weaning foods

Baby rice/porridgeBaby rice/porridge

Root vegetablesRoot vegetables

Fruit e.g. apple, pear, bananaFruit e.g. apple, pear, banana Check content of all baby jars/packetsCheck content of all baby jars/packets

Practical Weaning AdvicePractical Weaning Advice

After 6 monthsAfter 6 months Introduce protein e.g. meat, poultry, pulsesIntroduce protein e.g. meat, poultry, pulses Introduce wheat over 1 week e.g. breakfast Introduce wheat over 1 week e.g. breakfast

cereals, egg-free pasta, couscouscereals, egg-free pasta, couscous Widen variety of fruits and vegetablesWiden variety of fruits and vegetables Introduction of dairy, egg and fish depends on Introduction of dairy, egg and fish depends on

nature of child’s hypersensitivity reaction and nature of child’s hypersensitivity reaction and results of allergy tests, if appropriate to carry outresults of allergy tests, if appropriate to carry out

Practical Weaning AdvicePractical Weaning Advice

Introduce new food every 2-3 daysIntroduce new food every 2-3 days Small amounts of new food initially, Small amounts of new food initially,

particularly for more allergenic foodsparticularly for more allergenic foods Offer egg in more processed of forms Offer egg in more processed of forms

initially e.g. cake, egg pastainitially e.g. cake, egg pasta Remember:Remember:

- Thermic effect of food – redness on face- Thermic effect of food – redness on face - New acidic foods may lead to rash around - New acidic foods may lead to rash around

mouth (use vaseline around mouth)mouth (use vaseline around mouth)

Examples of Finger FoodsExamples of Finger Foods Rice cakesRice cakes Slices of soft fruitSlices of soft fruit Cooked vegetablesCooked vegetables Soft dried fruits e.g. apricots, figs, prunes, Soft dried fruits e.g. apricots, figs, prunes,

sultanassultanas Slices of cucumberSlices of cucumber Milk free dry breakfast cerealsMilk free dry breakfast cereals Toast with a milk free spreadToast with a milk free spread Cooked Pasta ShapesCooked Pasta Shapes Minature meatballsMinature meatballs Commercial milk free baby biscuits / baby ‘crisps’Commercial milk free baby biscuits / baby ‘crisps’

Weaning High Risk Infants Not Weaning High Risk Infants Not Diagnosed With Food AllergyDiagnosed With Food Allergy

High risk defined as a parent or sibling High risk defined as a parent or sibling with an atopic historywith an atopic history

Over-restriction by parentsOver-restriction by parents No need to restrict allergenic foods over 6 No need to restrict allergenic foods over 6

months but introduce new foods one at a months but introduce new foods one at a time and wheat over a period of a weektime and wheat over a period of a week

Food Allergy & Intolerance Specialist Group – May 2005Food Allergy & Intolerance Specialist Group – May 2005

Nutritional ConsiderationsNutritional Considerations

Cutting out Cutting out → → Missing out on Missing out on major foodsmajor foods important nutrients important nutrients

Faltering growth – diet can be limited in Faltering growth – diet can be limited in fat, particularly if milk freefat, particularly if milk free

Vegetarian children with dietary exclusions Vegetarian children with dietary exclusions may have very restricted dietsmay have very restricted diets

The more foods avoided, the more The more foods avoided, the more nutrients are at risk of deficiencynutrients are at risk of deficiency

Nutritional ConsiderationsNutritional Considerations

Good sources of:Good sources of:Calcium, protein, fat, fat soluble Calcium, protein, fat, fat soluble vitamins, Iodine, Magnesium, vitamins, Iodine, Magnesium, PhosphorusPhosphorus

EnergyEnergy

B1, B2, Niacin, IronB1, B2, Niacin, Iron

IronIron

B12, B2, folateB12, B2, folate

Nutritional Considerations - Nutritional Considerations - ExamplesExamples

Soya milkSoya milkNeed to check fortified with calciumNeed to check fortified with calcium

Contains similar amount of calories as Contains similar amount of calories as skimmed milkskimmed milkLow in fatLow in fat

Wheat free breadWheat free breadOrdinary white bread fortified with Ordinary white bread fortified with Calcium, Iron, Niacin, ThiaminCalcium, Iron, Niacin, ThiaminWheat free breads are not fortified, Wheat free breads are not fortified, smaller slices and more expensivesmaller slices and more expensive

Management of Exclusion DietsManagement of Exclusion Diets

Aim to keep child on their formula Aim to keep child on their formula substitute until at least 2 years of substitute until at least 2 years of age unless they outgrow their milk age unless they outgrow their milk protein hypersensitivity prior to protein hypersensitivity prior to thisthis

Avoid goat and sheep’s milk due to Avoid goat and sheep’s milk due to large degree of cross reactivitylarge degree of cross reactivity

Alternative MilksAlternative Milks

Alternative milks: Rice milk, soy milk, oat Alternative milks: Rice milk, soy milk, oat milksmilks

Can be used in food preparation over the Can be used in food preparation over the age of a year age of a year

Low in calories and lack the amount of Low in calories and lack the amount of fortification with vitamins and minerals fortification with vitamins and minerals that infant formulas have to meetthat infant formulas have to meet

Buy versions that are fortified with Buy versions that are fortified with calcium. Rarely used as a main milk drink calcium. Rarely used as a main milk drink < 2years due to poor nutritional content< 2years due to poor nutritional content

Management of Exclusion DietsManagement of Exclusion Diets

Choose products fortified with calciumChoose products fortified with calcium Soy ProductsSoy Products

Yogurts, desserts, custard, cheeses, Yogurts, desserts, custard, cheeses, chocolate, ice cream, creamchocolate, ice cream, cream

Soya exclusionSoya exclusionMay be difficult to obtain adequate May be difficult to obtain adequate calcium depending on intake of calcium depending on intake of breastmilk/milk substitutebreastmilk/milk substituteVery restrictive as soy found in many Very restrictive as soy found in many productsproducts

Alternatives to WheatAlternatives to Wheat Examples of suitable grains: Rice, corn, Examples of suitable grains: Rice, corn,

soya, buckwheat, millet, polenta, quinoa, soya, buckwheat, millet, polenta, quinoa, tapioca, maize, oats, sagotapioca, maize, oats, sago

Rye and barley often excluded due to Rye and barley often excluded due to similarity of proteins to wheat but may be similarity of proteins to wheat but may be tolerated by some childrentolerated by some children

Ensure specialist products are wheat free Ensure specialist products are wheat free and not just gluten freeand not just gluten free

Examples of wheat free productsExamples of wheat free productsPasta, bread, crackers, pizza bases, Pasta, bread, crackers, pizza bases, biscuits, cereals, flour, cakesbiscuits, cereals, flour, cakes

EU directive: Food Labelling Laws EU directive: Food Labelling Laws (Nov 2005)(Nov 2005)

14 allergens to be declared14 allergens to be declared Applies only to packaged Applies only to packaged

manufactured foods manufactured in manufactured foods manufactured in EU EU

Foods sold-loose are not includedFoods sold-loose are not included Further info on Food Standards Further info on Food Standards

Agency websiteAgency website ‘‘May contain’ labelling is not directly May contain’ labelling is not directly

covered by legislationcovered by legislation

Allergy LabellingAllergy Labelling

Cow’s milkCow’s milk EggsEggs SoyaSoya PeanutsPeanuts Tree nutsTree nuts Grains containing Grains containing

glutengluten

* Foods added in Dec ‘07* Foods added in Dec ‘07

SesameSesame FishFish CrustaceansCrustaceans MustardMustard CeleryCelery SulphitesSulphites Molluscs*Molluscs* Lupin*Lupin*

Useful WebsitesUseful Websites

www.goodnessdirect.co.ukwww.goodnessdirect.co.uk – extensive – extensive website for special diet foodswebsite for special diet foods

www.ok-foods.co.ukwww.ok-foods.co.uk – wheat, gluten and – wheat, gluten and dairy free biscuits, cakes and snacksdairy free biscuits, cakes and snacks

www.food.gov.ukwww.food.gov.uk – government food – government food standards agency websitestandards agency website

www.www.foodyoucaneatfoodyoucaneat.com.com – for extensive – for extensive recipes sent in by website usersrecipes sent in by website users

www.specialdietsconsulting.co.ukwww.specialdietsconsulting.co.uk – eating – eating out, recipes, informationout, recipes, information

Useful WebsitesUseful Websites

www.anaphylaxis.org.ukwww.anaphylaxis.org.uk www.allergyinschools.org.ukwww.allergyinschools.org.uk – –

information from the Anaphylaxis information from the Anaphylaxis Campaign for nurseries, pre-schools Campaign for nurseries, pre-schools and schoolsand schools

www.epipen.co.ukwww.epipen.co.uk

ReferencesReferences

Complementary feeding: a commentary by Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterology Nutr. 2008 Pediatr Gastroenterology Nutr. 2008 Jan;46(1):99-110Jan;46(1):99-110

Practical dietary prevention strategies for Practical dietary prevention strategies for infant at risk of developing allergic infant at risk of developing allergic diseases. The British Dietetic Association diseases. The British Dietetic Association Food Allergy and Intolerance Specialist Food Allergy and Intolerance Specialist Group. May 2005Group. May 2005