1. Complementary Feeding in Children with Food Hypersensitivity Jo Caines Paediatric Specialist Dietitian

2. Introduction of Solids Complementary feeding – all solids and liquid foods other that breast milk of infant formula Complementary feeding – all solids and liquid foods other that breast milk of infant formula Exclusive breastfeeding for the first 6 months of an infant’s life (Department of Health 2003) Exclusive breastfeeding for the first 6 months of an infant’s life (Department of Health 2003) Infant feeding survey (2005) Only 49% parents wait until 17 weeks to introduce solids Infant feeding survey (2005) Only 49% parents wait until 17 weeks to introduce solids

3. Weaning Recommendations Exclusive breastfeeding for 26 weeks is desirable Exclusive breastfeeding for 26 weeks is desirable Complementary feeding should not be introduced before 17 weeks and not later than 26 weeks Complementary feeding should not be introduced before 17 weeks and not later than 26 weeks No convincing evidence that avoidance or delayed introduction of potentially allergenic foods beyond 4-6 months reduces allergies No convincing evidence that avoidance or delayed introduction of potentially allergenic foods beyond 4-6 months reduces allergies ESPGHAN 2008 ? Delaying exposure to high risk foods increases the risk of allergy ? Delaying exposure to high risk foods increases the risk of allergy

4. Introduction of Allergenic Foods Most common food allergens in children: Most common food allergens in children: Cow’s milk, egg, peanuts (wheat / soy / fish) No guidelines as to how these foods should be introduced in children with known food allergy except for peanuts to be delayed until 3 years (DoH) No guidelines as to how these foods should be introduced in children with known food allergy except for peanuts to be delayed until 3 years (DoH) LEAP study LEAP study

5. Practical Weaning Advice 4 – 6 months Smooth puree Smooth puree Dairy, egg, soy, wheat, fish and nut free Dairy, egg, soy, wheat, fish and nut free Appropriate initial weaning foods Appropriate initial weaning foods Baby rice/porridge Root vegetables Fruit e.g. apple, pear, banana Check content of all baby jars/packets Check content of all baby jars/packets

6. Practical Weaning Advice After 6 months Introduce protein e.g. meat, poultry, pulses Introduce protein e.g. meat, poultry, pulses Introduce wheat over 1 week e.g. breakfast cereals, egg-free pasta, couscous Introduce wheat over 1 week e.g. breakfast cereals, egg-free pasta, couscous Widen variety of fruits and vegetables Widen variety of fruits and vegetables Introduction of dairy, egg and fish depends on nature of child’s hypersensitivity reaction and results of allergy tests, if appropriate to carry out Introduction of dairy, egg and fish depends on nature of child’s hypersensitivity reaction and results of allergy tests, if appropriate to carry out

7. Practical Weaning Advice Introduce new food every 2-3 days Introduce new food every 2-3 days Small amounts of new food initially, particularly for more allergenic foods Small amounts of new food initially, particularly for more allergenic foods Offer egg in more processed of forms initially e.g. cake, egg pasta Offer egg in more processed of forms initially e.g. cake, egg pasta Remember: Remember: - Thermic effect of food – redness on face - New acidic foods may lead to rash around mouth (use vaseline around mouth) - New acidic foods may lead to rash around mouth (use vaseline around mouth)

8. Examples of Finger Foods Rice cakes Rice cakes Slices of soft fruit Slices of soft fruit Cooked vegetables Cooked vegetables Soft dried fruits e.g. apricots, figs, prunes, sultanas Soft dried fruits e.g. apricots, figs, prunes, sultanas Slices of cucumber Slices of cucumber Milk free dry breakfast cereals Milk free dry breakfast cereals Toast with a milk free spread Toast with a milk free spread Cooked Pasta Shapes Cooked Pasta Shapes Minature meatballs Minature meatballs Commercial milk free baby biscuits / baby ‘crisps’ Commercial milk free baby biscuits / baby ‘crisps’

9. Weaning High Risk Infants Not Diagnosed With Food Allergy High risk defined as a parent or sibling with an atopic history High risk defined as a parent or sibling with an atopic history Over-restriction by parents Over-restriction by parents No need to restrict allergenic foods over 6 months but introduce new foods one at a time and wheat over a period of a week No need to restrict allergenic foods over 6 months but introduce new foods one at a time and wheat over a period of a week Food Allergy & Intolerance Specialist Group – May 2005

10. Nutritional Considerations Cutting out → Missing out on Cutting out → Missing out on major foods important nutrients Faltering growth – diet can be limited in fat, particularly if milk free Faltering growth – diet can be limited in fat, particularly if milk free Vegetarian children with dietary exclusions may have very restricted diets Vegetarian children with dietary exclusions may have very restricted diets The more foods avoided, the more nutrients are at risk of deficiency The more foods avoided, the more nutrients are at risk of deficiency

11. Nutritional Considerations Good sources of: Calcium, protein, fat, fat soluble vitamins, Iodine, Magnesium, Phosphorus Energy B1, B2, Niacin, Iron Iron B12, B2, folate

12. Nutritional Considerations - Examples Soya milk Soya milk Need to check fortified with calcium Contains similar amount of calories as skimmed milk Low in fat Wheat free bread Wheat free bread Ordinary white bread fortified with Calcium, Iron, Niacin, Thiamin Wheat free breads are not fortified, smaller slices and more expensive

13. Management of Exclusion Diets Aim to keep child on their formula substitute until at least 2 years of age unless they outgrow their milk protein hypersensitivity prior to this Aim to keep child on their formula substitute until at least 2 years of age unless they outgrow their milk protein hypersensitivity prior to this Avoid goat and sheep’s milk due to large degree of cross reactivity Avoid goat and sheep’s milk due to large degree of cross reactivity

14. Alternative Milks Alternative milks: Rice milk, soy milk, oat milks Alternative milks: Rice milk, soy milk, oat milks Can be used in food preparation over the age of a year Can be used in food preparation over the age of a year Low in calories and lack the amount of fortification with vitamins and minerals that infant formulas have to meet Low in calories and lack the amount of fortification with vitamins and minerals that infant formulas have to meet Buy versions that are fortified with calcium. Rarely used as a main milk drink < 2years due to poor nutritional content Buy versions that are fortified with calcium. Rarely used as a main milk drink < 2years due to poor nutritional content

15. Management of Exclusion Diets Choose products fortified with calcium Choose products fortified with calcium Soy Products Soy Products Yogurts, desserts, custard, cheeses, chocolate, ice cream, cream Soya exclusion Soya exclusion May be difficult to obtain adequate calcium depending on intake of breastmilk/milk substitute Very restrictive as soy found in many products

16. Alternatives to Wheat Examples of suitable grains: Rice, corn, soya, buckwheat, millet, polenta, quinoa, tapioca, maize, oats, sago Examples of suitable grains: Rice, corn, soya, buckwheat, millet, polenta, quinoa, tapioca, maize, oats, sago Rye and barley often excluded due to similarity of proteins to wheat but may be tolerated by some children Rye and barley often excluded due to similarity of proteins to wheat but may be tolerated by some children Ensure specialist products are wheat free and not just gluten free Ensure specialist products are wheat free and not just gluten free Examples of wheat free products Examples of wheat free products Pasta, bread, crackers, pizza bases, biscuits, cereals, flour, cakes

17. EU directive: Food Labelling Laws (Nov 2005) 14 allergens to be declared 14 allergens to be declared Applies only to packaged manufactured foods manufactured in EU Applies only to packaged manufactured foods manufactured in EU Foods sold-loose are not included Foods sold-loose are not included Further info on Food Standards Agency website Further info on Food Standards Agency website ‘May contain’ labelling is not directly covered by legislation ‘May contain’ labelling is not directly covered by legislation

18. Allergy Labelling Cow’s milk Cow’s milk Eggs Eggs Soya Soya Peanuts Peanuts Tree nuts Tree nuts Grains containing gluten Grains containing gluten * Foods added in Dec ‘07 Sesame Sesame Fish Fish Crustaceans Crustaceans Mustard Mustard Celery Celery Sulphites Sulphites Molluscs* Molluscs* Lupin* Lupin*

19. Useful Websites www.goodnessdirect.co.uk – extensive website for special diet foods www.goodnessdirect.co.uk – extensive website for special diet foods www.goodnessdirect.co.uk www.ok-foods.co.uk – wheat, gluten and dairy free biscuits, cakes and snacks www.ok-foods.co.uk – wheat, gluten and dairy free biscuits, cakes and snacks www.ok-foods.co.uk www.food.gov.uk – government food standards agency website www.food.gov.uk – government food standards agency website www.food.gov.uk www.foodyoucaneat.com – for extensive recipes sent in by website users www.foodyoucaneat.com – for extensive recipes sent in by website users www.foodyoucaneat.com www.specialdietsconsulting.co.uk – eating out, recipes, information www.specialdietsconsulting.co.uk – eating out, recipes, information www.specialdietsconsulting.co.uk

20. Useful Websites www.anaphylaxis.org.uk www.anaphylaxis.org.uk www.anaphylaxis.org.uk www.allergyinschools.org.uk – information from the Anaphylaxis Campaign for nurseries, pre-schools and schools www.allergyinschools.org.uk – information from the Anaphylaxis Campaign for nurseries, pre-schools and schools www.allergyinschools.org.uk www.epipen.co.uk www.epipen.co.uk

21. References Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterology Nutr. 2008 Jan;46(1):99-110 Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterology Nutr. 2008 Jan;46(1):99-110 Practical dietary prevention strategies for infant at risk of developing allergic diseases. The British Dietetic Association Food Allergy and Intolerance Specialist Group. May 2005 Practical dietary prevention strategies for infant at risk of developing allergic diseases. The British Dietetic Association Food Allergy and Intolerance Specialist Group. May 2005