1. Sophie Puttock, Children’s Dietitian

2. Issues include? Unsettled babies Colic/wind or cow’s milk protein allergy??? Problems accepting textures Weaning stage or later Babies with known difficulties NICU, CP, poor feeders and tube fed. Fussy eating

3. Breast feeding – is best Nutritional Better balance of nutrients More digestible, with enzymes Better absorption Anti-infective Less gastroenteritis & respiratory infections Complete nutrition in the first 6 months 50% energy from fat Essential fatty acids No additional fluids necessary

4. Standard Formulas ManufacturerWheyCasein Cow & GateFirst Infant MilkInfant Milk For Hungrier Babies MilupaAptamil First Infant Milk Aptamil Hungry Infant Milk WyethSMA First Infant Milk SMA Extra Hungry Infant Milk Amino acid profile of whey most like breastmilk Faster gastric emptying and less reflux on whey No evidence that hungrier babies are more satisfied on casein milks

5. Issues with infant formula…… Overfeeding (which can lead to reflux) Parents might feed according to tin instructions not “listening/watching” baby signs Underfeeding Making up incorrectly/unsafe practice “Marketing” Can encourage parents to switch to different milk through age and stage recommendations, not usually necessary to change formula if baby settled and thriving.

6. Other milks…………. Anti reflux. Comfort. Lactose free. Soya Wysoy only. For the older child Goats Oat/soya/nut/hemp Calcium important!

7. Is it cow’s milk protein allergy (CMPA)? Just to set the scene: 6-8% of children have a food allergy in the first 3 years of life Milk 2.5%, Egg 2%, Peanut 1% 2-4% of adults have a food allergy (6-8% adults have a perceived allergy) 85% of children outgrow food allergy in the first 5-10 years of life Typically with milk, egg and or soya

8. Signs and Symptoms (NICE CG116: 2011) IgE mediated Acute diarrhoea/vomiting Asthma or wheeze Difficulty breathing Exacerbation of eczema Hives or urticaria Itching, rashes, redness Pallor Swelling of lips,eyes,face Non IgE mediated Abdominal pain, bloating, colic, wind Constipation Loose/frequent stools Eczema Gastro-oesophageal reflux disease Vomiting (delayed) Food refusal/aversion Faltering growth

9. CMPA pathway for use in Primary Care Developed across Dorset – considers NICE, MAP, current evidence and local practice Available on Intranet Provides guidance for diagnosis of CMPA (non-IgE mediated) Information contained in appendices can be printed off and given to parents.

10. Suspicion of Non IgE mediated CMPA Slower onset over 2 hours or longer One or more of the following: Skin symptoms Gastro symptoms Respiratory symptoms Appendix B Allergy focused history Appendix A Suspicion of IgE mediated CMPA Rapid onset within minutes to 2 hours One or more of the following: Urticaria Wheeze Anaphylaxis Appendix B Refer to Paediatrician For Urgent advice or Rapid Access Clinic If exclusive breast feeding Check feeding technique Strict maternal milk free diet for 2-4 weeks Appendix C Milk free weaning from 6months Appendix D If formula feeding Extensively hydrolysed formula (EHF) for 2-4 weeks Appendix E Milk free weaning from 6 months Appendix D If mixed breast and formula Strict maternal milk free diet Appendix C Plus Extensively hydrolysed formula (EHF) for 2-4 weeks Appendix E Milk free weaning from 6 months Appendix D ImprovementNo improvement Eliminate soya as well for 2-4 weeks Appendix HAppendix Hi or Hiior Hii If exclusive breast feeding Re-introduce cow’s milk into maternal diet Appendix FAppendix F If symptoms return this confirms CMPA diagnosis Restart maternal milk free diet Appendix C Milk free weaning from 6 months Appendix D If formula feeding or mixed feeding Re-introduce cow’s milk formula Appendix G If symptoms return this confirms CMPA diagnosis Continue with EHF and/or restart maternal milk free diet Appendix EAppendix E Milk free weaning from 6 months Appendix D Telephone advice from Paediatrician (see above) or Children's Dietitian CMPA less likely Gradual return to normal diet Refer to Paediatrician if symptoms persist Partial improvementStill no improvement Appendix 1

11. Extensively hydrolysed and amino acid based formula - CMPA The following are those used most commonly in local practice:

12. So what if it isn’t CMPA? Reassurance/growth Check positioning and quality of feeding (HV) Assess lip seal, sucking/gulping Try not to switch milks too soon and too frequently Often out of your control – lead by peers/parents/media Careful advice re timing of weaning If wean before have oral skills to cope could put baby at nutritional risk

13. “Breastfeeding is the best form of nutrition for infants. Exclusive breastfeeding is recommended for the first six months (26 weeks) of life as it provides all the nutrients a baby needs” “6 months is the recommended age for the introduction of solid foods for infants” “Breastfeeding and/or breastmilk substitutes if used should continue beyond the first 6 months along with appropriate types and amounts of solids” Department of Health, May 2003 Weaning – when?

14. Weaning before 6 months of age Mothers who are unable or choose not to follow these recommendations should be supported to optimise their infants’ nutrition. COMA (1994) guidelines on not introducing solids before 17 weeks still stand in this situation May be associated with increased risk of obesity, food allergy, and gastroenteritis Evidence suggests gut, kidney and neuromuscular development are not adequate or mature enough for safe introduction of solids before this time

15. 6 – 9 months Learning to use lumps and pieces Purees with soft lumps Finger foods – soft carrot, melon, apple, toast, rusk Move quickly onto iron rich foods

16. 9 – 12 months Learning to eat with the family Chopped food can use fish fingers, sausages, nuggets Self feeding with the spoon Aim 5 tastes of fruit and vegetables daily

17. 6 months and older – vitamins? Breast milk, infant formula or follow on milk should remain as the main milk drink for under 1’s. 500ml per day formula to maintain iron and vitamin intakes. If taking less than 500ml formula or breastfeeding, give vitamins A, D & C. Solids given close to breast feed reduce iron absorption. All children aged 6 months to 5 years should be given vitamin drops (A,C and D)

18. What about babies and children with known difficulties? Ex-NICU, CP and those requiring tube feeding should have regular input from the team at PGH including the Dietitians. Individual needs will be assessed and advised on direct to yourselves or through liaison with the Health Visitors.

19. Fussy eaters Very common, often precipitated through parental anxiety or poor parental diets. Child needs to learn to deal with different textures/foods, if delayed (for whatever reason)can make this stage a long process. Very rare that it is due to a physical difficulty in an otherwise well child who is meeting developmental milestones. Can be related to sensory issues – sticky, messy Growth monitoring and patience - important tool for reassurance.

20. Fussy Eaters. Messy play and food play For the family – the messier the better Finger paints with lemon curd/ketchup, home made play dough-add edible glitter, colouring, etc No pressure/attention Reward progress, ignore negative behaviour. Can be a long process – for some children it may take weeks to accept a new food.

21. For further local information. Dorset Breastfeeding Policy Nov 2011 – to be updated this summer Dorset Child and Maternal Nutrition Guidelines Dec 2010 – being updated now Suspected Cow’s Milk Protein Allergy in Infants and Children March 2014. Children’s Dietitians at Poole Hospital 01202 442840 – we are always happy to talk to you and can send you patient information to give out.

22. Any Questions?