Feeding our children. Anna J Richards NZRD Kidzhealth

Transcription

1 Feeding our children Anna J Richards NZRD Kidzhealth

2 Feeding our children Raising competent eaters and falling off the feeding continuum

3 Competetant eaters have: Positive attitudes about eating and about food What is a competent eater? Food acceptance skills that support eating an ever-increasing variety of the available food Internal regulation skills that allow intuitively consuming enough food to give energy and stamina and to support stable body weight Skills and resources for managing the food context and orchestrating family meals Identifying these four constructs allows nutrition professionals to target interventions as well as trust and support the individual's own capabilities and tendency to learn and grow. Eating competence: definition and evidence for the Satter Eating Competence model. Satter E 1. J Nutrition educ behave 2007 Sep- Oct;39(5 Suppl):S

4 Barriers to creating competent feeders Adverse food reactions Delayed introduction of complimentary foods Limited tactile experiences the rise of busy clean freaks Lack of texture progression purees and pouches Poor feeding modelling monkey see, monkey do Modern cuisine The iron issue Health issues Physical discomfort allergy, intolerance, medical

5 When did the child fall off the feeding continuum and why?

6 Climbing on to the feeding continuum

7 Effects of repeated exposure to either vegetables or fruits on infant s vegetable and fruit acceptance at the beginning of weaning 101 healthy babies (4-6 months old) randomly assigned to either vegetable or fruit puree: For 18 days On day 19 the vegetable group received apple puree and the fruit group received green bean puree Barends et al 2013 Food Quality & Preference 29:2

8 Results These findings confirm that at the first exposure fruit acceptance is higher than vegetable acceptance. Starting with vegetables, but not with fruits, may promote vegetable acceptance in infants.

9 Babies randomised prior to starting solids Intervention group received exposure to vegetable puree added to milk (12 days), followed by vegetable puree added to baby rice (twice a day for 12 days) Control group received plain milk and rice Both groups then received vegetable puree (11 days) Intake was weighed and liking rated Appetite Jan;84:280-90

10 Results Fig. 3. Mean (SEM) vegetable intakes recorded each day in the laboratory (D25, 26, 33, 34, 35) and at home (D27, 28, 29, 30, 31, 32). Mothers reported appreciation of the structure and guidance of this systematic approach. Early exposure to vegetables in a step by-step method could be included in CF guidelines and longer term benefits assessed by extending the exposure period. Appetite, Volume 84, 2015,

11 An exploratory trial of parental advice for increasing vegetable acceptance in infancy Study conducted in Greece, Portugal and the UK Babies recruited between 4-6 months and randomised to the intervention or control group Intervention Group Vegetables First Parents provided with advice on providing 5 single vegetables over the first 15 days VS Control Group Parents provided with standard advice on complementary feeding Babies intake (g) and liking of an unfamiliar vegetable were assessed 1 month post-intervention. Aim: To investigate the impact of advising parents to introduce a variety of single vegetables as first foods on infants subsequent acceptance of a novel vegetable. Fildes et al. British Journal of Nutrition (2015)

12 An exploratory trial of parental advice for increasing vegetable acceptance in infancy Babies intake (g) and liking of an unfamiliar vegetable were assessed 1 month post-intervention. These results were not seen in babies from Portugal or Greece as they already have a vegetable first approach Fildes et al. British Journal of Nutrition (2015)

13 Is there any evidence that early acceptance of vegetables persists into childhood? Breast feeding promotes vegetable acceptance Offering babies a high variety of vegetables during complementary feeding increases acceptance of new ones Repeated exposure to a disliked vegetable increases acceptance BUT do these findings persist into childhood?

14 The Lasting Influences of Early Food-Related Variety Experience: A Longitudinal Study of Vegetable Acceptance from 5 Months to 6 Years in Two Populations Study Design 15 months 3 years 6 years BF or FF babies assigned to: Puree carrot for 9 days 3 vegetables changed every 3 day 3 vegetables changed daily On day 12 & 23 they received the new vegetable (courgette/tomato then peas) Several weeks later received 2 new foods meat and fish Followed up in the short term, 15 months, 3 and 6 years Maier-Nöth et al 2016 PLoS ONE 11(3): e

15 Results Short term follow up Results showed that type of milk feeding and experience with vegetable variety in the early complementary period influenced subsequent acceptance of new foods. Breastfed babies who experienced daily changes of vegetables had a higher intake and liking for new foods (courgette/tomato, peas, meat & fish). Maier et al 2008 Clinical Nutrition 27:849

16 Results Follow up at 6 years old Early food-related variety experience is associated with higher intake of new vegetables. A: for breast-fed and formula-fed infants; B: for the three experimental groups (no, low and high variety).

17 Key messages for Early Life Nutrition What advice did parents receive? 1. The importance of introducing vegetables early 2. Beneficial effects of offering different single vegetables each day 3. Techniques of exposure feeding 4. Interpreting infants facial reactions to food 5. The need for persistence when an infant initially rejects a food Why, what and how to introduce vegetables Parents welcomed the simple & prescriptive instructions

18 Solids. Moving on from baby led weaning

19 The rise of pouch foods - pros and cons

20 Predominance of apple, pear, mango = high fructose

21 Tactile experiences important in novel food acceptance

22 Are our children missing out on early tactile experiences?

23 The sore tummy epidemic

24 Over represented caesarean, antibiotics, mastitis, ear infections, rotovirus, gastroenteritis? Altered microbiome? Coeliac disease The sore tummy epidemic Constipation/ diarrhoea Feeding environment and increased loads - Sugar free alternatives Paelo families dates, almond, coconut, frooze balls Anna J Richards NZRD

25 The sore tummy brigade Altered gut microbiome predisposing - caesarean birth - antibiotics in mother whilst breastfeeding or child - frequent antibiotics - post infectious Environment increased load

26 Positive or negative fructose breath test results do not predict response to fructose restricted diet in children with recurrent abdominal pain: results from a prospective randomized trial. Wirth S 1, Klodt C 1, Wintermeyer P 1, Berrang J 2, Hensel K 1, Langer T 1, Heusch A 1. OBJECTIVES: To perform a prospective, blinded, randomized interventional trial in patients with recurrent abdominal pain. The primary endpoint was to determine the abdominal pain intensity after 2 weeks of fructose restricted diet. Secondary endpoints were changes of pain frequency and a secondary symptom score (SSS). METHODS: 103 individuals with recurrent abdominal pain for more than 3 months were randomized. 51 patients were allocated to group A (diet) and 52 to group B (no diet). 2 weeks later the patients underwent hydrogen breath test and were assigned to the test positive or negative group to identify patients with fructose malabsorption. RESULTS: 2 weeks after intervention the pain score decreased significantly from a median 5.5 in group A to 4 and did not change significantly in group B (5.3 to 5). In group A both patients with positive and negative breath tests had a significant lower pain score (-2 and -1.75, respectively). Frequency of abdominal pain decreased in both groups but without significant difference, SSS improved only in group A from median 6 to 3.5. Positive breath test was no predicting factor, neither was abdominal pain during the test. CONCLUSIONS: Fructose restricted diet in children and adolescents with recurrent abdominal pain may be of benefit to improve both abdominal pain symptoms and other secondary symptoms. Since a negative breath test result does not exclude a positive response to fructose restriction, the hydrogen breath test does not seem to be the appropriate diagnostic mean to predict the response to the diet. Klin Padiatr Sep;226(5): doi: /s Epub 2014 Aug 25. Anna J Richards NZRD

27 Fermentable Oligosaccharides FODMAPs Disaccharides Monosaccharides and Polyols

28 Increasing FODMAP load Commercial flavour bases - onion, garlic Inulin Fructose Sorbitol Liquid sugar free medicines Anna J Richards NZRD

29 Apples (53%), Water, Cooked Oats (13%) (Wheat 1 ), Apple Juice, Oat Bran (3%), Inulin (Dietary Fibre), Natural Flavour, Cinnamon Extract, Food Acid (Citric Acid)

30 Did granny know best?

31 Targeted approach in children Fructose apple, pear, mango, honey, dried fruit Lactose Fructans wheat, rye, onion, garlic GOS legumes, almonds Polyols stone and pip fruit, kumara, sugar free preparations ( eg Pamol)

32 Diarrhoea in Infants Milk allergy Other food allergies Lactose intolerance FODMAP load

33 Dietary factors in constipation in infants Formula concentration Inadequate fluid Milk allergy Soy allergy Wheat allergy FODMAP load

34 Constipation in children Milk allergy - IgE 85% resolution by 6-7 years - non-ige typically resolves first 2-3 years Coeliac disease 1/100? 1/85-85% undiagnosed Functional gut disorder FODMAPS - caesarean birth over represented - frequent antibiotics - post-infectious IBS symptoms

35 IgE mediated food allergy IgE mediated food allergy can result in mild, moderate or severe (anaphylaxis) reactions Source: Adapted from Boyce et al. JACI, 2010.

36 IgE mediated milk allergy IgE mediated most prevalent allergy <12mo Diagnosis hx + SPT or Specific IgE - often cutaneous presentation ( eczema, urticaria, hives) - timing < 2hours Tolerance gradual and stepwise milk ladder Resolution 85% by age 6-7

37 Signs and symptoms of mild to moderate food allergic reactions Swelling of lips, face, eyes Hives or welts Tingling mouth Abdominal pain, vomiting Eczema or rashes

38 Non-IgE mediated allergy Non-IgE gut reactors Milk, soy, wheat Diagnosis no specific testing - hx + exclusion + rechallenge - timing delayed and cumulative Tolerance gradual and stepwise milk ladder Resolution - <3 yrs

39 Include IgG testing, cytotoxic food testing, kinesiology, Vega testing, electrodermal testing, pulse testing, reflexology and hair analysis Are not scientifically validated and may lead to unnecessary, costly and dangerous avoidance strategies Are not Medicare rebated in Australia Are not recommended by ASCIA or any allergy society worldwide Further information is available from the ASCIA website Unproven and inappropriate diagnostic methods

40 Natural history of food allergy Milk, egg, soy and wheat allergy commonly resolve Peanut, tree nut, sesame, fish and shellfish allergy usually persist 85% of young children in population based studies outgrow their allergy to milk or egg by age 3-5 years Ref: Cohen A

41 Breastfeeding First formula First solids baby rice Step-up formula ( incr Dalton size of protein molecules) Early exposure to whole CMP ( milk, cheese, yoghurt) Presentation of milk allergy

42 Mechanism of adverse reaction determines management strategy and avoids over-restriction Important to identify mechanism of adverse reaction to milk

43 Allergy immune driven hyper-response to protein Milk allergy v lactose intolerance Lactose intolerance not immune driven - enzyme deficiency (lactase) - subsequent fermentation of lactose - abdominal pain, bloating, flatulence, diarrhoea - altered large bowel osmotic load Primary lactose intolerance uncommon?? Prevalence stats Mangement- typically dairy free diet Secondary lactose intolerance altered gut microbiota - post infectious - coeliac disease Management typically resolves over time - low lactose diet ( lactose free milk, avoid major sources of lactose, hard cheese ok)

44 Lactose Intolerant - primary Lactase drops concurrent with breastfeeding Lactose free formula or milk or soy milk NB Rice, almond, oat milk not nutr equivs NB all mammal milks contain lactose ** graphic lactose contents of foods Yoghurt soy ( NB coconut not nutr equiv) Cheese not commonly tolerated Butter usually tolerated Baked milk not usually tolerated

45 Secondary lactose intolerance Milk lactose free milk ( fresh or UHT) or formula or soy NB All mammal milks contain lactose NB Rice, almond, oat etc not nutr complete Yoghurt LF or soy Soft cheese +/- small quantities Hard cheese yes Baked milk yes Commercial baked milk yes NB Caution in toppings and flavourings

46 Feeding options for infants with confirmed CMA Ref: Vandenplas et al, Allen et al, 2009.

47 Milk options NOT recommended for infants with confirmed CMA Infant formulas that are NOT recommended: Cows milk based including anti-reflux Lactose free cow s milk based Partially hydrolysed (phf) cow s milk based (labelled HA) Goat milk/other animal milk based formula Other preparations that are NOT recommended: A2 (cows) milk cross reactivity Other mammalian milks cross reactivity Rice drink nutritional concerns Oat drink nutritional concerns Home-made cereal/soy drinks nutritional concerns Coconut milk (often contain cow s milk) Ref: Allen KJ et al, 2009

48 Auto-immune Prevalence 1/100? 1/85 First degree relative Not born with develop at any stage Coeliac disease

49 Presentation altered bowel motions ( constipation +/- diarrhoea) -flatulence -bloating - FTT poor growth and weight gain - poor calcification of teeth - poor iron and B12 status - alopecia or poor hair growth - poor appetite, self elimination - behaviour off Coeliac disease

50 Bloods TTG ( iron, B12) Small bowel biopsy NB Continue to consume gluten throughout diagnosis Coeliac disease - diagnosis

51 The birth story The early life story Its all in the history. Early feeding Solids Concurrent events Finger feeding Messy play

52 Lets raise happy eaters