1. Community Paediatric Service
558 referrals received from Luton GP’s/ Health Visitors/ School Nursing in 2016.
Specialities include –allergy, faltering growth, obesity (under 5 yrs), vitamin & mineral deficiencies, learning disabilities/ restrictive diets.
Deliver 7x community clinics per month and manage a caseload of tube fed infants and children across South Bedfordshire and Luton.
My name is Sarah Wocka, I currently work as part of the community paediatric team for SEPT. We are a team on 2 (soon to be 3 clinical paediatric dietitians). In addition to the community team we also have a public health team who deliver the family food first project within nurseries in Luton focusing on under 5’s nutrition, oral health and physical activity.

2. Food hypersensitivity
Is a reproducible sign or symptom which is produced after consuming a certain type of food.
WAO (2010) estimates % of children suffer with cow’s milk protein allergy.
Perceived food allergy could be up to 10 times higher.
Cow’s milk allergy may be defined as a reproducible adverse reaction to one or more milk proteins mediated by one or more immune mechanisms.
Food allergy
Food intolerance
Cow’s milk allergy may be defined as a reproducible adverse reaction to one or more milk proteins (usually caseins or whey b-lactoglobulin) mediated by one or more immune mechanisms (A) [5]. The underlying immunological mechanism distinguishes cow’s milk allergy from other adverse reactions to cow’s milk such as lactose intolerance [6]. Cow’s milk allergy is classified by the underlying immune mechanism, timing of presentation and organ system involvement. The commonest reactions are IgE mediated occurring within minutes, the majority within an hour, following the ingestion of small amounts of cow’s milk (A). Presentation varies in severity ranging from mild symptoms in the majority to, rarely, life-threatening anaphylaxis and involving the skin, respiratory tract, gastrointestinal tract, and cardiovascular system. (BSACI guidelines 2014)
Cows’ milk allergy - affects around 3-6% of (3-6 in every 100) infants and young children who usually start to have symptoms in their first few months. This causes many health problems and is frequently not diagnosed, or takes many months to be diagnosed.
Most children outgrow milk allergy by five years of age so true milk allergy in older children and adults is extremely uncommon.
IgE mediated
Non-IgE mediated

3. CMPA treatment - formula fed
Follow prescribing guidelines: Summarised
1st line – Similac Alimentum (<6m) & Nutramigen 2 (>6m) – EHF
Casein dominant.
2nd line – Aptamil Pepti 1 – EHF (<6m) or 2 (>6m)
Use if infant not accepting first line due to taste.
Whey dominant.
Contains some lactose.
3rd line – Neocate LCP (from birth) – AAF
Usually started in specialist or secondary care.
If severe/multiple allergy.
If symptoms not resolved with EHF.
Key points:
The majority of infants (90%) should respond to an extensively hydrolysed formula, an amino acid based formula should only be considered if the infant has severe IgE mediated allergies, severe eczema and faltering growth.

4. Soya formula/ alternatives
Not recommended for infants less than 6 months of age due to phytoestrogen in soya formula.
There is a risk of co-existing soya and cow’s milk allergy
Infant over 6 months could be prescribed if EHF refused.
Soya yogurts/deserts are suitable as alternatives over 6 months of age.
Soya formula may be used second line after 6 months of age if first line is not accepted –this is to be purchased over the counter by the family and not prescribed.

5. What is lactose intolerance (LI)?
Lactose is the sugar in milk and dairy products.
LI occurs when lactose not absorbed in gut.
Symptoms are lower gut related:
abdominal pain, bloating, increased wind, loose green stools.
Primary LI does not usually present until later childhood or adulthood.
Secondary LI occurs post gut trauma – usually resolves on its own.
Lactose intolerance may be suspected in infants but only require treatment in those where symptoms persist for more than 2 weeks
Improvement should be seen within 48 hours of excluding lactose, if within 7 days the symptoms are on-going consider cow’s milk protein allergy
Breastfed – continue to be fed as normal if secondary lactose is suspected. No change to maternal diet is required as lactose levels cannot be altered
Formula fed infants may not require LF formula initially, if symptoms have persisted for more than 2 weeks, trial with a lactose free formula OTC, if started solids use in conjunction with a lactose free diet. Use LF for 2-8 weeks allow symptoms to resolve and gut to recover, gradually reintroduce standard formula and dairy foods (if over months into the diet)
Use of lactose drops is NOT recommended i.e colief
If over 1 year of age and lactose intolerance is suspected use a full fat lactose free cow’s milk in supermarket.

6. Taste Testing
Similac Alimentum
Nutramigen LGG 2
Neocate LCP

7. Gastro oesophageal reflux disease
GOR – normal process, very common – provide reassurance to parents.
GORD – reflux of gastric contents causes severe symptoms that warrant medical treatment.
Thickened formulas should only be used as part of stepped care approach – NICE guideline 1 (NG1).
Over the Counter OTC use first line:
Cow & Gate or Aptamil Anti-reflux OR SMA staydown.
Thickened formula to use first line if a prescription is required:
Enfamil AR (to be used for those with ongoing reflux concerns).
Gastro oesophageal reflux is a common condition which involves the passage of gastric contents into the oesophagus with or without vomiting.
Gastro oesophageal reflux disease is when the passage of gastric contents into the oesophagus causes symptoms or complications that are severe enough to warrant medical treatment
NICE guidance NG1 – encourages clinicians to look out for red flags which indicate disorders other than GOR i.e. projectile or bile or blood stained vomit, diarrhoea, fever etc…
Infants presenting with GOR usually do not require treatment.
If formula fed infants present with frequent vomiting & marked distress (suggestive of GORD) a stepped care approach is recommended:
Review feeding history, then
Reduce feed volumes only if excessive for infants weight ( no more than 150ml/kg/day), then
Trial smaller, more frequent feeds, then
Offer a trial of a thickened formula.
A referral to the 0-19 team may be helpful to manage first line advice
Parents should be directed to over the counter formulas first line, a prescription may be warranted if thickened formula is an effective treatment and the infant requires this for on going reflux problems.
Review after 2 weeks, if there is no improvement offer alginate therapy for a trial period.
If prescribing the formula review efficacy of the prescription after 6 months of age – as reflux tends to improve with age.
For breastfeeding infants – refer to the 0-19 team for breastfeeding assessment.

8. Specialist Infant Formulas – Pre term
Pre-term formula’s Nutriprem 2 powder (900g tin) or SMA Gold prem 2 powder (400g tin)
Use until 3-6 months corrected age
Corrected age = gestational age-number of weeks premature
Remember:
Children born weeks –correct until 1 year
Children born very pre-term (<32 weeks) corrected until 2 years
Ensure that there is an end date for prescription
A pre- term formula maybe commenced upon discharge from hospital for infants born before 34 weeks gestation and/or weighing less than 2kg at birth. These formula’s should only be started in secondary care. The formula’s should be stopped if the infant is older than 6 months corrected age. It may be stopped prior to this if the infant is on solid food or excessive weight gain. If stopped earlier than 6 months a prescription for sytron and other vitamins as stated in department of health guidelines. Pre-term infants may be discharged on liquid preparations but this is rare.
Calculating corrected age:
Gestational correction is required when plotting babies born before 37 weeks gestation. It is important to correct for prematurity in the first 2 years of life.
When calculating corrected age, subtract nine weeks from the actual age since birth date.
For example if a child who is born at 31 weeks gestation (9 weeks early) when a child is 1 year and 26 weeks the corrected age will be one year and 17 weeks. (26-9=17 weeks)

9. Oral Nutritional Supplements – Paediatrics
Paediatric super shakes (homemade recipes)
Fortini/Fortini Multifibre (1.5kcal/ml)
Fortini Smoothie multifibre (1.5kcal/ml)
Fortini 1.0 multifibre
Calogen
FP10-disease related malnutrition, growth failure
In certain circumstances, for children with poor weight gain or malnutrition as a result of a medical condition who have not improved growth or weight gain through changes to the diet alone an oral nutritional supplement maybe considered.

10. Gluten Free Products

11. Thank you for listening
Any questions?

12. References
Food first-
Food First Team (SEPT) South Bedfordshire
Telephone: , Fax
BAPEN-
National Institute for Health and Clinical Excellence (NICE) -
NHS Choices-