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