NUTRITION AND DIETETIC DEPARTMENT PROFESSIONAL CONSENSUS STATEMENT GUIDANCE FOR

NATIONAL SCHOOL LUNCH PROGRAM BULLETIN WWWEEDSTATEAKUSTLSCNS CHILD NUTRITION
1 TITLE THE EVOLUTION OF HOME ENTERAL NUTRITION (HEN)
10 MANAGING SEVERE ACUTE MALNUTRITION STUDY SESSION 10 MANAGING

13 NUTRITION AND HYDRATION PREPARATION STORAGE DISPENSING AND CONSUMPTION
13 NUTRITION INFORMATION SYSTEM SESSION 13 NUTRITION INFORMATION SYSTEM
14 EFFECT OF EARLY NUTRITION ON CARCASS AND

CLINICAL STANDARS AND GUIDELINES FOR COWS MILK PROTEIN INTOLERANCE/ALLERY

NUTRITION AND DIETETIC DEPARTMENT


PROFESSIONAL CONSENSUS STATEMENT


GUIDANCE FOR COW'S MILK PROTEIN INTOLERANCE/ALLERGY


TARGET GROUP


Children (0-18) who have been clinically and dietetically assessed and found to be, or for investigation of cow's milk protein intolerance/allergy.


AIM OF DIETETIC INTERVENTION


  1. To enable parent/carer/child to exclude all dietary sources of cow's milk protein.

  2. Maintain a nutritionally complete diet, which meets the child’s need, including an adequate calcium and vitamin D intake.


TEAM AIMS


  1. To improve symptoms relating to cow's milk protein intolerance/allergy.

  2. To achieve and maintain the appropriate centile for height and weight.


STANDARDS


Parent/carer/child is given information to enable:


  1. Appropriate selection of milk substitutes. There are many types of milk available, choosing the appropriate formula will be dependent on the individual case, clinical presentation, age, palatability and nutritional status.


Breast Milk


Exclusive breast feeding is method of choice for six months. Cows milk protein B lactoglobulin can be detected in the milk of 95% lactating women but is tolerated by the majority of infants with cows milk protein allergy/intolerance. However if symptoms persist, (often in infants with severe atopic eczema or enterocolitis), a trial of cows milk protein free diet for mother may be needed. It is important to ensure an adequate calcium and vitamin D intake for the mother ( see appendix 1).


For infants where breast milk is not an option then a suitable infant formula should be used.




















Hypoallergenic formulas available in the UK


Type of Formula

Name of Formula

Age restriction

Comments

Extensively hydrolysed casein

Ist line at HEFT <6 months age

Nutramigen lipil 1

(mead and Johnson)


1st line at HEFT >6months age

Nutramigen lipil 2

Mead and Johnson)

Birth to 6 months



6months to 2 years

Contains higher level of pepties below 1.5Kd.


Well tolerated in children with IgE mediated allergy



Extensively hydrolysed casein

Pregestimil

(Mead and Johnson)

Birth to 2 years

Contains 54% MCT

Extensively hydrolysed whey

Pepti 1

(Aptamil)





Pepti 2

(Aptamil)

Birth to 6months





6 months to 2 years

Contain 40% lactose


Whey empties the stomach faster so may be of benefit to children with gastrointestinal symptoms


Addition of lactose improves taste

Extensively hydrolysed whey

Pepti-Junior

(Cow and gate)

Birth to 2 years

Contains 50% MCT


Can be used as first line if MCT is indicated

Non milk bases extensively hydrolysed formulas

Prejomin

(Milupa)


Peptide

(SHS)


MCT Peptide

(SHS)

From birth

Contain meat derivatives so not suitable for certain cultures, religions or vegetarians. Poor taste

Soya Formulas

SMA Wysoy




Cow & Gate Infasoy

From 6 months to 2 years

Not recommended for children under 6 months (see appendix 2)


Alternatively Alpro Junior 1+ can be used from the age of 1 year in place of formula


Beyond 2 years calcium rich soya milk can be used as an alternative source of milk

Elemental amino acid based formula

Neocate LCP 1ST line at HEFT if symptoms persist with extensively hydrolysed formula




Nutramigen AA (Mead and Johnson)

From birth until infant has grown out of allergy

Indicated when hydrolysed formulas do not resolve symptoms or when there is a evidence of severe/multiple allergy









At HEFT we use Nutramigen 1 and 2 or Pepti Junior (if MCT indicated) as our first line infant formula. If symptoms persist then Neocate LCP is used. It is estimated that upto 10% infants will continue to react to extensively hydrolysed formula due to the residual cows milk protein peptides.


Infants over 6 months of age often reject the introduction of hypoallergenic formula due to the poor taste compared to breast milk / standard infant formula. To help this :

  1. Hypoallergenic formula should be introduced as soon as possible. If breast feeding continues then use incremental mixing of the two milks to aid transition.

  2. Offer the hypoallergenic formula as the only fluid source

  3. If over 6 months of age introduce the formula in a beaker

  4. Mask the smell with a few drops of vanilla essence

  5. As last resort mix hypoallergenic formula with commercial milkshake powders (as these are high in sugar and create a sweet preference). Once the formula is established gradually reduce the amount of milkshake powder added until formula is tolerated neat.



Older Children ( over 12 months of age)


Continue with breast milk or suitable formula. If on Neocate LCP, Neocate Active (1-10yrs) or Neocate Advance (1-10yrs) can be used . Neocate Active contains more calcium and iron. If child is having a soya formula, Alpro 1+ could be introduced if diet adequate.


Other mammalian milks (sheep, goat, horse,water buffalo) have similar milk proteins to cows milk and thus harbour an allergic potential and are not suitable alternatives to cows milk.


Replacement milks ( rice, oat, soya, pea,coconut) have a poor nutrient content compared to cows milk. There are lower in calories, protein, fat soluble vitamins and minerals. If used the calcium enriched varieties should be advised.


Due to concerns regarding arsenic levels in rice milk the food standard agency advises it should not be given in children under 4 1/2 years of age ( see appendix 3).


  1. Successfully follow a strict cow's milk free diet.

  2. Achieve a nutritionally adequate diet that meets estimated requirements. When necessary, appropriate dietary supplements e.g. Calcium and Vitamin D are recommended.

  3. To achieve/maintain the child’s expected weight for height.

  4. To obtain prescription if required for milk substitute on FP10 form from the child’s GP. (See appendix 4 for prescribing guidelines)



MEASURE OF SUCCESS


Parent/carer/child is able to:


  1. Use and incorporate cow's milk substitute as advised by the Dietitian.

  2. Avoid cow’s milk and its derivatives from the child’s diet.

  3. Provide a diet which is balanced and meeting child’s nutritional requirements.

  4. Achieve/maintain the child’s weight within the normal limits.

  5. Contact the Dietitian if needed.

  6. Obtain milk substitute on a prescription from the GP if appropriate.






RESOURCES









Pepti Junior Recipe & Information Booklet.




PROCESS


Parent/carer/child are seen in accordance to general standards for dietetic consultation: interview and documentation.


  1. Introduce yourself and explain the purpose of the consultation.

  2. Explain reasons for cow's milk protein exclusion.

  3. Measure weight and height, plot centile.

  4. Take a dietary history of present intake.

  5. Note clinical symptoms reported.

  6. Clearly outline sources of cow’s milk protein and derivatives.

  7. Identify sources included in current dietary intake.

  8. Explain food labelling.

  9. Recommend a suitable milk substitute and advise regarding use and incorporation into cow’s milk free diet.

  10. Advise on dietary practices as appropriate to child’s requirements and assess calcium intake.

  11. Provide parent/carer with written information to support advice.

  12. Dietitian’s name and contact number is given.

  13. Contact child’s GP if required to prescribe milk substitute where appropriate.


FOLLOW-UP










References


Food Hypersensitivity. Diagnosing and Managing Food Allergies and Intolerance. Isabel Skypala and Carina Venter . Wiley-Blackwell (2009)
















































Appendix 1


Daily Calcium requirements


AGE

Calcium required (mg)

0 – 12 months

525 mg

1 – 3 years

350 mg

4 – 6 years

450 mg

7 – 10 years

550 mg

Males 11 – 18 years

1000 mg

Males 19 + years

700 mg

Females 11 – 18 years

800 mg

Females 19 + years

700 mg

Breast Feeding

Female requirements + 550 mg



















Appendix 2



Paediatric Group of the BDA position statement

Use of infant formulas based on soy protein for infants (Oct 2010)



NUTRITION AND DIETETIC DEPARTMENT PROFESSIONAL CONSENSUS STATEMENT GUIDANCE FOR


Appendix 3

Arsenic in rice research published Thursday 21 May 2009

NUTRITION AND DIETETIC DEPARTMENT PROFESSIONAL CONSENSUS STATEMENT GUIDANCE FOR

The Agency has today published results from two studies: arsenic levels in rice drinks and one on cooking methods to reduce arsenic levels in rice. As a result of the rice drink study, the Agency recommends that toddlers and young children should not have rice drinks, often known as rice milk, as a replacement for cows’ milk, breast milk or infant formula.

The rice drink study followed concerns about results from a study published last year that measured arsenic levels in these types of drinks. The research published today examined 60 samples of rice drinks and found low levels of arsenic in all of them (see The science behind the story section below).

The level of total arsenic ranged from 0.010 - 0.034 milligram/kilogram and the levels of inorganic – the more harmful – form of arsenic ranged from 0.005 - 0.020 milligram/kilogram. The proportion of inorganic arsenic in the rice drink samples ranged from 48 - 63%. None of the results were over the current legal limit (but see the Current regulations section below).

In the second study, researchers looked at the effect of cooking methods on arsenic content of rice. The Agency is not advising anyone to change the way they cook rice as a result of this study as the impact on the overall dietary intake of arsenic from different cooking methods is minimal.

What the Agency advises

As a precaution, toddlers and young children between 1 and 4.5 years old should not have rice drinks as a replacement for cows’ milk, breast milk, or infant formula. This is because they will then drink a relatively large amount of it, and their intake of arsenic will be greater than that of older children and adults relative to their bodyweight. This is both on nutritional grounds and because such substitution can increase their intake of inorganic arsenic, which should be kept as low as possible. A daily half pint or 280 millilitres of rice drink could double the amount of the more harmful form of arsenic they consume each day.

There is no immediate risk to children who have been consuming rice drinks and it is unlikely that there would have been any long-term harmful effects but to reduce further exposure to arsenic parents should stop giving these drinks to toddlers and young children.

If your child is allergic to cows’ milk, you are strongly advised to seek advice from your health professional or dietitian on suitable replacements.

Other groups of people do not need to change their diet because their exposure to inorganic arsenic from rice drinks is lower relative to their bodyweight.

Children under a year old should drink breast milk or infant formula milk. Cows’ milk or alternatives are not suitable as a drink until an infant is 12 months old.

The research published today does not affect the Agency’s advice on any other weaning foods. Advice from a survey in 2007, which included baby rice and other rice products, concluded that these foods did not have levels of inorganic arsenic that caused concern.

Further information:

For further information on this survey, please contact: [email protected]

The science behind the story

Arsenic is widely distributed in the environment. It occurs in soil, water – both sea and fresh – and in almost all plants and animal tissues. As a result, arsenic occurs naturally at very low levels in many foods and it is not possible to avoid it completely. How harmful the arsenic is depends on the chemical form in which it is present. The organic form is less harmful than the inorganic form which can cause cancer by harming our genetic material (DNA). Rice and rice products have higher levels of the inorganic form of arsenic compared with other food. The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) (an independent scientific committee that provides advice to the Food Standards Agency) has concluded that people should consume as little of this form of arsenic as reasonably practicable.



Appendix 4

Guidelines for Prescribing Specialist Infant Formula in Primary Care September 2012. Full Document can be found on the ‘H’ Drive- Specialist Team Folders- Paediatric Team- Prescribing


NUTRITION AND DIETETIC DEPARTMENT PROFESSIONAL CONSENSUS STATEMENT GUIDANCE FOR

















Hdrive: Paed folder18.Stan.cows milk intol (April 2014)

(Review April 2016)



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