Complementary Feeding
in Children with Food
Hypersensitivity
Jo Caines
Paediatric Specialist Dietitian
Introduction of Solids
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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)
Infant feeding survey (2005)
Only 49% parents wait until 17
weeks to introduce solids
Weaning Recommendations
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Exclusive breastfeeding for 26 weeks is desirable
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
ESPGHAN 2008
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? Delaying exposure to high risk foods increases
the risk of allergy
Introduction of Allergenic Foods
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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)
LEAP study
Practical Weaning Advice
4 – 6 months
 Smooth puree
 Dairy, egg, soy, wheat, fish and nut free
 Appropriate initial weaning foods
Baby rice/porridge
Root vegetables
Fruit e.g. apple, pear, banana
 Check content of all baby jars/packets
Practical Weaning Advice
After 6 months
 Introduce protein e.g. meat, poultry, pulses
 Introduce wheat over 1 week e.g. breakfast
cereals, egg-free pasta, couscous
 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
Practical Weaning Advice
Introduce new food every 2-3 days
 Small amounts of new food initially,
particularly for more allergenic foods
 Offer egg in more processed of forms
initially e.g. cake, egg pasta
 Remember:
- Thermic effect of food – redness on face
- New acidic foods may lead to rash
around mouth (use vaseline around
mouth)
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Examples of Finger Foods
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Rice cakes
Slices of soft fruit
Cooked vegetables
Soft dried fruits e.g. apricots, figs, prunes,
sultanas
Slices of cucumber
Milk free dry breakfast cereals
Toast with a milk free spread
Cooked Pasta Shapes
Minature meatballs
Commercial milk free baby biscuits / baby ‘crisps’
Weaning High Risk Infants Not
Diagnosed With Food Allergy
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High risk defined as a parent or sibling
with an atopic history
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
Food Allergy & Intolerance Specialist Group – May 2005
Nutritional Considerations
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Cutting out
major foods
→
Missing out on
important nutrients
Faltering growth – diet can be limited in
fat, particularly if milk free
Vegetarian children with dietary exclusions
may have very restricted diets
The more foods avoided, the more
nutrients are at risk of deficiency
Nutritional Considerations
Good sources of:
Calcium, protein, fat, fat soluble
vitamins, Iodine, Magnesium,
Phosphorus
Energy
B1, B2, Niacin, Iron
Iron
B12, B2, folate
Nutritional Considerations Examples
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Soya milk
Need to check fortified with calcium
Contains similar amount of calories as
skimmed milk
Low in fat
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Wheat free bread
Ordinary white bread fortified with
Calcium, Iron, Niacin, Thiamin
Wheat free breads are not fortified,
smaller slices and more expensive
Management of Exclusion Diets
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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
Alternative Milks
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Alternative milks: Rice milk, soy milk, oat
milks
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
Buy versions that are fortified with
calcium. Rarely used as a main milk drink
< 2years due to poor nutritional content
Management of Exclusion Diets
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Choose products fortified with calcium
Soy Products
Yogurts, desserts, custard, cheeses,
chocolate, ice cream, cream
Soya exclusion
May be difficult to obtain adequate
calcium depending on intake of
breastmilk/milk substitute
Very restrictive as soy found in many
products
Alternatives to Wheat
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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
Ensure specialist products are wheat free
and not just gluten free
Examples of wheat free products
Pasta, bread, crackers, pizza bases,
biscuits, cereals, flour, cakes
EU directive: Food Labelling Laws
(Nov 2005)
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14 allergens to be declared
Applies only to packaged
manufactured foods manufactured in
EU
Foods sold-loose are not included
Further info on Food Standards
Agency website
‘May contain’ labelling is not directly
covered by legislation
Allergy Labelling
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Cow’s milk
Eggs
Soya
Peanuts
Tree nuts
Grains containing
gluten
* Foods added in Dec ‘07
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Sesame
Fish
Crustaceans
Mustard
Celery
Sulphites
Molluscs*
Lupin*
Useful Websites
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www.goodnessdirect.co.uk – extensive
website for special diet foods
www.ok-foods.co.uk – wheat, gluten and
dairy free biscuits, cakes and snacks
www.food.gov.uk – government food
standards agency website
www.foodyoucaneat.com – for extensive
recipes sent in by website users
www.specialdietsconsulting.co.uk – eating
out, recipes, information
Useful Websites
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www.anaphylaxis.org.uk
www.allergyinschools.org.uk –
information from the Anaphylaxis
Campaign for nurseries, pre-schools
and schools
www.epipen.co.uk
References
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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