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2 Nutricia Paediatric Food Allergy Expert Meeting The speaker had sole editorial control over the content in this slide deck. Any views, opinions or recommendations expressed in the slides are solely those of the speaker and do not necessarily represent those of Nutricia.

3 Heidi Ball Paediatric Allergy Dietitian Children s Allergy Service. University Hospitals of Leicester

4 Children with milk allergy beyond 1 year of age The majority of children with CMA develop tolerance by adulthood 1,2 but tolerance maybe a gradual process over 6 12 months following baked milk introduction with whole milk last to be tolerated. Some children may be slower to develop tolerance 2,3 particularly those with: Multiple food allergies Greater sensitivity (higher spige result) Allergic rhinitis/asthma + CMA Therefore for many children with Cow s Milk Allergy, a milk substitute is needed over the age of 12 months 1 Wood, R. J All Clin Immunol. 2013; 13(3): Luyt et al. Clinical & Experimental All (44) Skripak, J.M. et al. J All Clin Immunol 2007; 120(5):

5 The effect of food allergies on growth of children Compared to healthy controls, children with food allergy have lower weight per length percentiles and lower BMI Avoidance of milk allergen has most effect of weight for length and BMI Effect is worse in those with > 2 allergen avoidance Higher incidence of Feeding problems Dietetic involvement improves outcome Hobbs CB, Skinner AC, Burks AW, Vickery BP. J All Clin Immunol Pract (1): Meyer, R, et al. Clinical and Translational Allergy :25

6 Overview role of milk in the older child What are available as a milk substitutes Nutritional difference between choices What role does a milk substitute play in the older child (do we need one?) Case examples

7 Milk Substitute Choices for older child 1) Continue Breast Feeding Check infant on Vitamin drops (Vit D assessment) Variety of solids (iron) Weight/growth adequate Discuss plan to continue breast feeding Assess maternal diet, especially if dietary exclusions

8 Milk Substitute Choices for the Older Infant 2) Continue current infant formula Ideally 500ml minimum Consider change to stage 2 (6 months+) for some infant formula e.g. Nutramigen 2, Aptamil Pepti 2 for increased Iron and Calcium Check formula choice is still appropriate e.g. tolerating soya in food? Change to soya? Check weight and height

9 Milk Substitute Choices for the Older Child 3) Change to a specialist complete allergen free formula for 1 10 years Neocate Advance 1Kcal/ml Amino Acid Formula Nutritionally complete formula for children 1-10 years Unflavoured 100g sachet/400ml or banana-vanilla 50g/200ml Neocate Active 1Kcal/ml Amino Acid Formula Supplement with extra protein, calcium, iron, vitamins Unflavoured or blackcurrant 63g sachet made up to 300ml (Infatrini Peptisorb)

10 Milk Substitute Choices 4) Alternative Milk Drinks

11 Why do parents switch to milk drinks? 1. He was doing so well on infant formula but the tin said suitable 0 12 months so I thought I had to stop it 2. The GP has stopped the prescription and told me to buy cartons from the supermarket 3. The dietitian said I could use some coconut milk for cereals so I just thought it would be easier to swap for everything I needed to stop breast feeding and he just hates the taste of the special formulas

12 What age can alternative milk drinks be given???

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14 Milk Drinks what do they really contain? 100ml Almond Milk = 95 ml Water, 1 ¾ Almonds, (3g Sugar), 1.2g salt, (Calc & Vits)

15 Nutrients in Milk Drinks Nutrient (per 100ml) Breast /formula (AAF follow on Neocate Active) Cows Milk FF/SSK/SK AMD 1 Alpro (Almond) AMD 2 Oatly (Oat) AMD 3 Organic (Coconut) Kcal / 46 / Protein (g) Fat (EFA) (g) /1.7/ (x) Sugar (g) Salt (g) Iron (mg) Riboflavin (mg) / Vit D (µg) tr / Calcium (mg) / B12 / Vit A (µg) 0.2/56 0.1/ / / / 0 /

16 Soya drinks Nutrient Cow s Milk Soya growing up drink Alpro 1-3 Soya Drink unsweetened supermarket Kcal Protein (g) Sugar (g) / Salt (g) / Riboflavin (mg) / Vit D (µg) tr 1.5 / Calcium (mg) / Iron (mg) B12 (µg) / / Vit A (µg) 30 0 (+iodine and Vt C) /

17 Soya Drinks Fortified Soya drink as a substitute is the best nutritionally as a cow s milk substitute, if formula/breast is not continued. Reasons for exclusion: Allergy/intolerance Concerns re: phytoestrogens Sugar Cost

18 3 Cases of children with food allergy using alternative milk drinks Case 1 Milk Allergy, 15 months old (No soya) BF, dislikes formula. Mum keen to stop BF Good eater, mixed diet from all food groups 1 Banana ¼ slice bread and margarine Meat pasta bolognaise with cucumber sticks, fruit pouch 1 biscuit 1 Fish finger, mash, beans ½ fruit

19 Case 1: Nutrient analysis of solids eaten compared to (lower) reference amounts for age Dietary Intake Requirements (% of requirement achieved from diet) 500ml formula/ breast milk 500ml AAF follow on milk (Neocate Active) 500ml almond / coconut milk Energy (Kcal) (75%) Protein (g) (160%) Calcium (mg) (21%) Vit A (µg) (19%) Vit D (µg) (0.18%) Riboflavin (mg) (30%)

20 Case 1 - findings Case 1 requires a milk and soya free substitute that provides Energy, Calcium, Vitamin A, riboflavin and (Vitamin D) BUT what if things change/child with less varied diet? Vegetarian Delayed feeding skills/food refusal Losses, allergic reactions Catch up Inability to cook, financial, no dietitian??? A substitute containing protein will be essential How are you going to get extra energy in? (200kcals = 5 teaspoons fat)

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23 3 Cases of Children with food allergy using alternative milk drink Case 2 Milk, Wheat, Egg, Soya and Peanut allergy Fussy eater, Age 18 months ½ slice rice bread toast and margarine 6 grapes 1 bowl wheat free pasta and 10ml oil ½ packet french fries crisps Homemade potato and carrot soup + ½ slice rice bread Few chips, 1 rice cake with jam

24 Case 2: Nutrient analysis of solids eaten compared to (lower) reference amounts for age Dietary Intake Requirements (% of requirements achieved from diet) 500ml formula/ breast milk 500ml AAF follow on milk (Neocate Active) 500ml Alternative milk drink Energy (Kcal) (70%) Protein (g) (61%) Calcium (mg) (16%) (600) Vit A (µg) (25%) Iron (mg) (24%) Riboflavin (mg) (13%) (1) Vit B12 (µg) Vit C & folate also low Vit C: +17 Folate: (1.9) No vit C No folate A substitute containing energy, PROTEIN, range of minerals and vitamins is preferable (essential)

25 3 cases of children with food allergy using alternative milk drinks Case 3 Milk Allergy Age 4 Good eater Dry cereal (Cheerio's) 2 biscuits Prawns, noodles and broccoli. Fruit Homemade muffin Roast pork, 2 roast potatoes, carrots and peas, gravy Apple crumble, no custard

26 Case 3: Nutrient analysis of solids eaten compared to reference (lower) values for age Dietary Intake Requirements (% of requirements achieved from diet) Energy (Kcal) (95%) Protein (g) (>100%) Calcium (mg) (79%) Vit A (µg) (>100%) Iron (mg) (>100%) Riboflavin (mg) (100%) Vit D no concern/supplement optional Using an alternative milk drink would increase calcium, ensure Vitamin D and allow increased variety e.g. custard, sauces, cereals

27 Alternative Milks Over the age of 1 year - Summary Breast Milk, Formula, Alternative Milk Drink (Follow-on AA) advised ALL under 1, most under 2 and under 4 in certain cases No meat eaten (or vegetarian equivalent protein source) Multiple food group exclusion Poor weight/growth Catch up growth needed Feeding problems Low volume intake No monitoring available May still need Calcium/Vits NOT under 1 year, under 2 only with close supervision. Soya is best nutritionally Good eater (mixed diet from all food groups especially protein) Following centile for weight and height (and monitor) All should be on multi Vit and assessed for Calcium Single food exclusion No Rice milk under 4.5 (arsenic)

28 Conclusions Alternative milk drinks are not equivalent to breast or formula milk nutritionally low on in energy and many other nutrients (iron,vit A, Riboflavin, iodine etc) most contain NO or very low protein Advertised as healthy but this can be misleading for use in children Labelled as fortified, but? measures in place to monitor actual amount added and no evidence available on absorption e.g. of calcium (also?separation in carton). More expensive so the quantity taken may be low Suitable for children with allergy for the purposes of cooking/meal improvement BUT not as a nutritional drink (dietetic supervision needed). Soya milks are nutritionally equivalent in (energy) and protein, but may need Calcium and Vitamins if not fortified. They should be offered over 1 year unless medical reason (soya intolerance, requirement for ehf or AA formula)

29 Conclusions Formula/breast to age 2 minimum is recommended (BSACI, WAO and local guidelines) for children with milk allergy A nutritionally complete low allergen follow on milk should be considered for; - multiple food allergy and milk/soya exclusion - Requirements not being met by BF/infant formula - Poor weight gain/growth in child with food allergy A flavoured low allergen follow on milk is of benefit for; - Refusal of formula due to taste (especially BF) - Poor volume of formula In multiple food allergy, this may need to continue past age 2!