Cow's milk protein weaning

Normally we'll see your referral from the GP or the Paediatrician. And then we

invite you to a group session, which we're doing via audio at the moment.

Usually within one month of receiving your referral, you should have contact from us, so hopefully you've found this in adequate time. We then invite you to the group session

and usually around the age of one year of age, we'll invite you again to another group session.

You can be under our care as long as your family needs to be, and that might be via

telephone or it might be a future group of appointments.

You're likely to have lots of questions, and hopefully this presentation today will answer a lot of them. However, don't worry if it doesn't.

Do make a note of any questions that you have and myself or Julia will be contacting you via telephone to answer any of your questions.

So this is the outline of the session. Today, we're going to be talking about what cow’s milk protein allergy is. We're going to be talking about symptoms and diagnoses. I'm also going to talk about what it isn't.

So, we're going to discuss:

·         Lactose intolerance

·         How to treat cow's milk protein allergy

·         Food labelling

·         Cow's milk-free weaning

·         Introducing other common allergenic foods into the diet

·         Cow's milk free alternative products

·         Looking at reintroducing cow's milk back into the diet in future

i will also talk about calcium and vitamin D.

What is cow's milk protein allergy?

Cow’s milk protein allergy is when the body reacts to proteins found in the milk. It's one of the most common food allergies to occur in children and it affects around two to five percent of children, so it's quite common.

There are two types of cow's milk protein allergy we can see:

Children who react immediately and their symptoms typically show within minutes of having

cow's milk protein.

This isn't quite as common as delayed reactions, which is the other type

of calcium protein allergy. This is when symptoms typically show within hours and sometimes days after having cow's milk protein.

What are the typical symptoms of cow's milk protein allergy?

Well, we tend to see children who have diarrhoea or constipation. Sometimes they have really bad tummy ache and nausea or reflux or vomiting.

Occasionally we can see some children who have blood in their stools and a lot of parents describe their children as holding their tummy and an arch in their back. So these are quite typical gastro symptoms that we see.

We also sometimes see children who have symptoms with their skin such as rashes or even a flare-up to eczema. It can sometimes affect the respiratory system and children can have runny or blocked noses.

Sometimes we can see some swelling of the face, eyes and lips. These are very rare and also we can sometimes see swallowing or breathing difficulties. But again, these are very

rare.

Reflux is a symptom that can occur in children who have cow’s milk protein allergy, but it can also occur on its own in around half of infants so it is quite common. Removing cow's milk protein from your child's diet can help the reflux but there are other measures that will help as well.

I would really recommend looking at the UNICEF baby friendly initiative website and the leaflets and videos that they have to help you around reflux.

People also want to know how cow’s milk protein allergy is diagnosed and unfortunately there aren’t any tests that we can do that are particularly reliable.

If your child's got delayed symptoms, then the main way that we find out if they've got a cow's milk protein allergy is by avoiding cow's milk protein for a period of time (usually around four weeks). After that, we look to reintroduce cow's milk protein into the diet

and if you've noticed an improvement in symptoms by removing it, and more symptoms when you reintroduce it, then that confirms the diagnosis.

If your child's having immediate reactions, there are some tests that may be used. However, a lot of the time these aren't particularly helpful and we look to see where symptoms have

improved when you've removed these foods from the diet.

Cow's milk protein allergy is very different to lactose intolerance. Lactose is the sugar in the milk and it's often confused with cow's milk protein allergy. A true lactose intolerance is very rare and it sometimes occurs after a bug.

The reason we talk about it today is to make sure that you don't use any of the lactose free products if your child's got a cow's milk protein allergy. They'll still get symptoms as the protein is still in those products.

What is the treatment of a cow's milk protein allergy?

It's a diet that is free from cow's milk and also any food that contains cow's milk.

We do often get asked with regards to other mammalian milk such as sheep or goat's

milk. Unfortunately these are also discouraged as the proteins are so similar, that if

your baby is reacting to cow's milk, they will likely react to these milks too.

If your child is under the age of 1 and they are formula-fed, you will receive a milk free formula on prescription until your baby is around one years of age.

If you are breastfeeding, we encourage this to continue. And if you have been able to tolerate dairy in your diet, then we would ask for you to continue to have dairy in your own breastfeeding diet, and only remove if you feel your child is reacting to the dairy you are eating as only a small amount of protein actually passes through the breast milk so which formulas are suitable for children with a cosmic protein allergy.

If you can see the formulas on the left-hand side of the screen, these are formulas known as extensively hydrolysed formulas, which include eutrangine lgg, similac elementum or  abdomal pepti. These are always the first line of formulas that we use in this area and hopefully they will resolve all of your children's symptoms.

On the right-hand side of the screen are the amino acid-based formulas, these are only used if your child's reactions are severe, or if we have any concerns with regards to their weight and some of these formulas are neakiet nutramigen per amino or alpha amino. We also get asked if soya formulas are appropriate in children with cosmic protein allergy. They're only

used in children who are over the age of six months and this will be discussed later on in

the presentation so checking food labels is really important when following a cow's milk free diet and it's always really essential to check every label of every product that will pass through your baby's lips. So any pre-packaged foods should, by law, have the ingredient cow's milk in bold.

Any foods without a packaging or foods served and whilst you are away from home should have some written information on, or you can ask the member of staff in the café, for example. Some items may have a ‘may contain’ warning, and these would indicate whether cow's milk may be an ingredient. Initially we would ask you to avoid these products. But hopefully, by checking the food label, you will know whether the product has cow's milk protein in it. Always check all medications and especially teething gels and crystals as some of these may contain cow's milk and these should be avoided.

Some of our top tips. Always check every single food label as you'll be quite surprised as to what contains cow's milk. If you ask at your local supermarkets at the customer services

section, they should have some lists on which items are cow’s milk free. Don't always assume that a free-from product will be free from the allergen you want it to be. For

example, if an item is gluten-free, it does not mean that it will be milk-free so always check your label.

Shopping online can be quite useful as you can see all the ingredients. But always check the

label once the item has been delivered. And at the bottom of the screen you'll see the red food maestro symbol, this is an app that we would highly recommend to use with food shopping.

Cow's milk-free weaning is exactly the same as weaning any baby, just ensuring that it is

cow’s milk protein free.

Weaning should occur around the age of six months, when your baby is naturally interested in food and also showing some good head control.

The leaflet that you received in the post will have some information on weaning in much greater detail so please look at the next few slides and also pages in your leaflet to look at some main ideas and also finger food ideas.

Suitable alternatives to milk that are available in the supermarkets

These can be used in cooking and food preparation over the age of six months. They are not

to be used as your baby's main drink until they are over the age of one. And please look at the label and try to ensure that they have added calcium.

Soya milk is not recommended in babies under the age of six months, but we do encourage you to try this once this age has been reached. Some babies with a cow's milk protein allergy may also have a soya allergy, therefore it is important to check if they have any symptoms which will be similar to your previous symptoms of a cow’s milk protein allergy. And remove if you feel they react.

Of the milks on the screen, you can see a wide variety and we would encourage the use of soy milks, oat milks and coconut milks for example. And ensure that they have added calcium.

When you check the label, there are also many cow’s milk free alternative products available in the supermarkets now. Thankfully, due to the recent trend in vegan products, these have increased the amount of items that are actually available.

These include spreads, cheese, yogurts and desserts such as ice creams and custards for example. These are widely available in most larger supermarkets. Please also see your leaflet for some other products available and some of the brand names.

A lot of parents ask us about introducing other foods into the diet, perhaps foods that people they know have had an allergic reaction to and parents are understandably sometimes

concerned about this. We think that by introducing the foods early into the diet, around six months, it reduces the risk of them developing an allergy so we would recommend that you introduce things like eggs and wheat, soya and even peanuts.

For peanuts we recommend using peanut butter as opposed to whole nuts just because of the choking risk involved with whole nuts. I think this is a food item that parents are particularly worried about, so we recommend using a really tiny amount. Perhaps the size of a grain of rice; just placing a small amount of peanut butter on their lips, waiting about 20 minutes and doing the same again. Because it might be the second time that they would have a reaction if they're okay. After the second time you can gradually increase the amount up and they'll be able to include this regularly then in their diet.

Like I said, we think that by introducing these foods early into the diet, it reduces the risk of them developing an allergy. We can't guarantee that they won't have a reaction however, so we do recommend trying it when they're well, when you're with them and you can observe them for the rest of the day. If you did notice any symptoms of any difficulty with breathing,

or perhaps if they were to become floppy, you would need to get medical advice urgently

and explain that you think they're having anaphylactic reaction. But I have to stress this is very unlikely to happen, and a lot of parents feel that they would prefer to do this at a time

when they're with them with a small amount and when they can get help if needed rather than waiting for them to perhaps get hold of it themselves.

So hopefully you'll be able to get a whole range of foods into your child's diet which will help them from a nutrition point of view and also from an enjoyment point of view.

Cow's milk is a really good source of calcium in the diet, so it's important that if you're avoiding

cow's milk that you get adequate source of calcium. A lot of the products have been fortified with calcium and you can check the labels to make sure that there's enough calcium in the products.

Also, in the diet sheet that you will have received, there's a whole page on calcium  requirements by age as it does change at different ages. You'll be able to work out how much calcium is in different products and how much calcium is enough for your child.

If you're breastfeeding, your calcium requirements are really high. That's 1250 milligrams of calcium, which is about five portions of dairy products. A portion would be a glass of milk, a

pot of yogurt, or a small matchbox size piece of cheese. So it's quite a lot and it's unlikely that you're going to be able to get all of this from your diet using the suitable alternatives if you are avoiding dairy. Therefore you would need to take a calcium supplement.

The other important nutrient is vitamin D. We need vitamin D to help take calcium into the body. We usually get vitamin D from the sunshine, which we don't always have enough of

in this area. It's recommended that all babies who are breastfed receive a vitamin D supplement from birth. And for those who are formula-fed, they'll need one once they're having less than 500 mls of formula. For example, you could use such as Abideck which you can get from the pharmacy. They used to be called healthy start and you may still be able to get healthy start vitamins.If not, just ask at your local pharmacist.

So the good news is that most children with cow's milk protein allergy do grow out of their allergy. Some of them will have grown out of it by the age of one and most of them by the age of three. Nearly everybody by the age of five.

For most children, it's completely safe to reintroduce milk protein back into the diet when the child is at home. The only time that we would consider an alternative would be if there'd been any immediate or severe reactions to cow's milk protein products. I would also recommend to hold off if your child has current severe atopic eczema.

If you've got any concerns, you can speak to your dietitian over the telephone. I'm going to pass you over to Julie to talk about how we go about doing the reintroduction.

So we now just want to introduce you to the milk ladder, which is what we'll use

to reintroduce cow's milk protein into your baby's diet when the time comes. We don't need to go into too much detail as we will be speaking to you again around this time.

Usually, once most babies have been progressing with the weaning coming up to their first birthday, we look to reintroduce dairy into the diet. The concept of the milk ladder is that when cow's milk protein is heated up and processed for a very long time, the body doesn't seem to react to it in the same way. So we start with something like a malted milk biscuit.

Obviously we're not expecting as strong reactions with small amounts of food either, so we would start with a small amount, usually around a quarter, and the symptoms can be delayed. We usually wait a couple of days and then try maybe for example a half of a malted milk biscuit. A couple of days later, we would increase that to three quarters and so on and so on. Like I said, we'll discuss this in more detail closer to the time. It's perhaps worth pointing out that at the top of the milk ladder is things like chocolate. So if your child is accidentally getting hold of things like chocolate, then they might still be getting some

symptoms.

So all that we want to say now is thanks very much for your time, and thanks for listening. There are lots of people who are there to help, like I said, myself or Julie. I'll be able to speak to you over the telephone but don't forget you've also got your health visitor who has a wealth of knowledge and support for you out there. And there's lots of useful websites included on the slides, which you can have a look at over the next few pages.

Once again, thank you so much for your time and we look forward to speaking to you soon.