What Milk?What Milk?

Jo CainesJo Caines

Paediatric Specialist DietitianPaediatric Specialist Dietitian

BreastfeedingBreastfeeding

11stst choice - continuation of breastfeeding choice - continuation of breastfeeding ? Mother may require exclusion diet if ? Mother may require exclusion diet if

child has severe eczema or child has severe eczema or gastrointestinal symptomsgastrointestinal symptoms

Most evidence with maternal exclusion Most evidence with maternal exclusion diets is for cow’s milk and eggdiets is for cow’s milk and egg

? Calcium supplementation for mother if ? Calcium supplementation for mother if excluding cow’s milkexcluding cow’s milk

Degree of HydrolysisDegree of Hydrolysis

Extensively Hydrolysed Casein Extensively Hydrolysed Casein Formula (EHC-F)Formula (EHC-F)

Nutramigen 1 Nutramigen 1 (£8.20/400g)(£8.20/400g)

Well tolerated in younger infantsWell tolerated in younger infantsUnpalatableUnpalatableNutramigen 2 > 6 monthsNutramigen 2 > 6 months Tastes better and has increased calciumTastes better and has increased calciumPregestimil Pregestimil (£8.91/400g)(£8.91/400g)

Similar formula containing increased levelSimilar formula containing increased levelof medium chain triglycerides useful in fat of medium chain triglycerides useful in fat

malabsorptionmalabsorption

Extensively Hydrolysed Whey Extensively Hydrolysed Whey FormulaFormula

Pepti Pepti (£17.10/900g)(£17.10/900g)

More palatable than extensively hydrolysed More palatable than extensively hydrolysed casein formulascasein formulasContains lactoseContains lactoseLarger peptides - ? Less well toleratedLarger peptides - ? Less well toleratedUseful in children who refuse EHC-FUseful in children who refuse EHC-F

Pepti Junior Pepti Junior (£9.42/400g)(£9.42/400g)

Contains MCT’sContains MCT’sDoes not contain lactoseDoes not contain lactoseMore expensive than PeptiMore expensive than Pepti

Amino Acid Amino Acid FormulasFormulas

Neocate LCP and Nutramigen AANeocate LCP and Nutramigen AASuitable for children with:Suitable for children with: - multiple food allergies - multiple food allergies

- children with food allergy and GI - children with food allergy and GI symptoms/faltering growthsymptoms/faltering growth

- failure of extensively hydrolysed - failure of extensively hydrolysed formulaformula

Expensive Expensive (Neocate £22.02/400g, NutramigenAA (Neocate £22.02/400g, NutramigenAA £21.22/400g)£21.22/400g)

Unpalatable but very effectiveUnpalatable but very effective

Amino Acid FormulasAmino Acid Formulas Neocate AdvanceNeocate Advance (£35.50/15x50g) (£35.50/15x50g) >1 year>1 year 1kcal ml1kcal ml Need large volumes to be nutritionally complete Need large volumes to be nutritionally complete

but can be used as a sole source of nutritionbut can be used as a sole source of nutrition Neocate Active Neocate Active (£49.12/14x63g)(£49.12/14x63g) > 1year> 1year 1kcal/ml1kcal/ml Increased iron and calcium to meet requirements Increased iron and calcium to meet requirements

in 600mlsin 600mls Designed as a supplement to dietDesigned as a supplement to diet

Soya FormulasSoya Formulas

Safety concerns regarding effect of Safety concerns regarding effect of phytoestrogens (COT 2003)phytoestrogens (COT 2003)

Cross reactivity with cow’s milk proteinCross reactivity with cow’s milk protein- Non IgE- Non IgE Up to 60%Up to 60%- IgE- IgE 17-47%17-47%

More palatableMore palatable SMA WysoySMA Wysoy(£7.58/860g)(£7.58/860g) / Cow & Gate Infasoy / Cow & Gate Infasoy

(£7.44/900g)(£7.44/900g) / Heinz Soya Nurture Formula / Heinz Soya Nurture Formula BDA Paediatric Group (2004)BDA Paediatric Group (2004)

- Avoid < 6/12 as a precautionary measure- Avoid < 6/12 as a precautionary measure- Vegans, Galactosaemia, CMPA refusing eHF- Vegans, Galactosaemia, CMPA refusing eHF

Partially Hydrolysed Partially Hydrolysed FormulasFormulas

Not suitable for cow’s milk protein Not suitable for cow’s milk protein allergy treatmentallergy treatment

More peptides with high molecular More peptides with high molecular weightweight

Antigen content reduced to avoid Antigen content reduced to avoid primary sensitisationprimary sensitisation

Example: NAN HA Example: NAN HA (£4.29/400g)(£4.29/400g)