Both Leonora and I know how tough it can be to wean a baby suffering with cows’ milk protein allergy (CMPA), with three of our children experiencing different problems. We got in touch with Dr Rosan Meyer, the UK’s leading specialist paediatric dietitian to give us some advice on where to start. If you have any questions on this topic you’d like answered, please drop me a line, firstname.lastname@example.org and we’ll do a follow-up.
How do you attempt to wean a CMPA baby – could you describe a plan for a first week in the weaning life of a CMPA baby?
In essence weaning a child with cow’s milk allergy is not different to weaning a child without allergies, as you still want to introduce vegetables and fruit first, and not delay the introduction of any other food allergens (i.e. egg, wheat, peanuts), unless the child is allergic to these. However, your healthcare professional may provide you with more individualised advice depending on the type of cow’s milk allergy your child has (immediate type versus delayed type) in regards to how long you should trial each food and also what foods need to be prioritised.
What simple meals do you recommend and how many times a day?
As food introductions are cumulative, you soon will be able to combine foods you have introduced into little meals. I usually suggest that as soon as you have 3-4 foods introduced 2 meals per day should be given and when protein like chicken/pulses/fish and introduced you can move to three times per day
What time of day is best to start giving food?
In an allergic child, new foods should be given in the morning or lunch time, to give time for observation.
Should a routine be kept?
When you have a child with CMPA, its ideal to have a routine around meal times and also a routine around introduction of foods, so that its easy to establish if symptoms are experienced to trace back any changes.
What’s the advised portion size for weaning in general?
This is the most common question parents ask and the answer is that there are no portion sizes for babies < 1 year of age. The reason for this is that babies grow at different rates and have different appetites and still grow. Responsive feeding has been shown to be the best way to feed babies: this means, that if a child signals satiety you stop and conversely if they are hungry you provide more.
Therefore, you may start with 1-2 teaspoons of weaning foods and your child may show signs of hunger, in which case you add another 1-2 teaspoons. It is important not to feed to a portion size that you as an adult has decided is adequate.
There are a couple of things to look out for, for which you will need specialist advice:
- Food refusal with associated weight dropping downwards in centiles (in the absence of acute illness like a gastro bug, as any child will not eat when not well)
- A child that does not stop eating with associated increase in weight centiles upwards.
When would you advise is a good time to start weaning with CMPA?
Most allergy guidelines suggest to weaning between 4- 6 months of age, when your baby is ready. Delaying weaning does not prevent any allergies, in fact there is some evidence to suggest that starting between 4-6 months, especially whilst breast feeding could help induce tolerance. Conversely it is not suggested to wean before 4 months of age.
Are there any foods that should be avoided by babies suffering with reflux as a symptom of CMPA?
There are no routine foods to be avoided because of reflux in CMPA. The reflux experienced in CMPA is different to standard reflux in babies and avoiding of acidic foods for example has no scientific basis.
When does one introduce water as a part of weaning instead of milk?
You would never introduce water instead of milk in a weaning diet. Water is an add on from 6 months of age and is not supposed to replace breast milk or formula, hence in particular in the initial phase of introduction only sips are suggested. If the weather is hot, you may want to increase the amount of water, but this is not to displace breast milk or formula feeding.
NHS choices has some information on water versus milk.
If a problem arises when weaning a child with CMPA – a skin reaction for example, what should I do? Stop, and go back to milk?
This really depends on the type of reaction, the severity, the food given and concomitant factors. For example, a rash with tomato is likely to be around the mouth is just a histamine response, which is common and not dangerous (comes quickly and goes quickly), conversely a rash with peanuts is much more worrying. In addition, fever (other illness) commonly leads to rashes, irrespective of new food introduced, which often leads to parents thinking this could be a food allergy.
If your child has a reaction, you would not stop feeding the foods your child already tolerates without any symptoms – these need to be continued. Just stop the food he/she reacted to and if it was not a severe reaction, trial again. In the case of common hypoallergenic foods, you will find that most children on second exposure tolerate this without reaction. If the reaction was severe and it includes foods that are common allergens (cow’s milk, egg, soya, wheat, nuts, shellfish) then would seek healthcare professional input prior to re-trialling.
Are there any other reactions besides obvious rashes that I should be looking out for? Ie. with silent reflux, there were obvious signs. Are these symptoms the same?
The NICE Guidelines on Food Allergy provide a list of common reactions divided by the type of allergy, which may occur.
A friend advised me to start giving my CMPA baby nuts as soon as possible. Is this right?
All allergens, outside of cow’s milk should be introduced from 6 months of age. This includes nuts (in nut butter format), egg, wheat, fish ect. There are specific high risk populations with eczema and skin prick test positive to egg, where a healthcare professional may recommend to introduce this earlier than 6 months.
Do we have to be prepared for other allergies and go about things differently in comparison to a non-CMPA baby?
In many of the children with CMPA you will find other allergies. In the immediate type CMPA you can get more direction to what other possible allergies are present with a skin prick test or IgE blood testing. In delayed CMPA there is no test and the best way to be able to establish if other allergies are present is to do introduction occur in a systematic. Your healthcare professional may provide you with a specific
Where do skin reactions typically occur and why do some parents report them being worse at nighttime?
There are many types of skin reactions, so it is difficult to class them together. Allergic related skin reactions, for example hives that itch, can occur at any time of the day following the ingestion of an allergenic food and can cover all parts of the body. You can also get histamine reactions, which typically occur around the mouth (cheeks), this rash comes quickly and goes quickly. Histamine release is driven by many factors including specific foods (like tomato, but this is not dangerous), a heat and anxiety (i.e. a baby crying), so a variety of factors can lead to more skin rashes at night. In children with eczema you will often find that the itching increases at night time because of temperature increase (being warm).
What does mucus in stools mean?
Babies can have mucus in the stool irrespective of having a diagnosis of food allergies. This can occur during teething and when unwell. If however mucus occurs in conjunction with other gastrointestinal symptoms (diarrhoea, blood, severe abdominal pain) then it may be a sign of gut inflammation.
What’s your opinion on baby rice?
Baby rice is a carbohydrate based porridge suitable from between 4-6 months of age. Recent research has indicated that baby rice contains some arsenic (both whole grain and standard baby rice), so its better to introduce this as part of a varied diet including a variety of other grains like millet/quinoa/buckwheat/polenta.
What do you think about shop bought pouches for dairy free children, or children in general? Why do they have such a long shelf life with no additives?
There is no research to say that shop bought pouches are harmful for babies, but many contain a high amount of fruit puree even in savoury meals, which may not be ideal for babies that prefer sweet food in any case. In addition recent evidence has shown also a difference in the bacteria in the gut of babies that have home cooked versus shop bought foods. It seems that home cooked foods give you a better gut bacteria variety, which may have long term health benefits. Shop bought pouches are also pureed in a way that you will never be able to puree a home, which often leads to babies wanting these because they are so smooth and refusing home made foods. An emerging problem with these commercial foods, is that these are given to babies to suck from directly from the pouch, which of course is not helpful for oral motor development as they know how to suck and need to learn eating and being messy is critical for this.
They last so long as they are cooked at very high temperature, packed in a sterile environment and the majority contain some form of vitamin C (i.e lemon juice), which is an anti-oxidant.
How do you phase out their hypoallergenic formula once food as been established, and does this happen after one year of age?
Hypoallergenic formula remains and important part of the diet of a child with CMPA until at least 1 year of age. Vitamin D and calcium intake is the limiting factor in phasing it out and ideally a dietitian should advise how to do this.
By Dr. Rosan Meyer
Specialist Paediatric Dietitian, RD
B.Dietetics, Post Grad Dipl Dietetics, M. Nutrition, PhD
Tel: +44 (0)7526 694 172
84 Harley Street, London W1G 7HW
Blog: Step by Step Kidz Nutrition