Prescribing Specialist Infant Formula For Proven and Suspected Cow s Milk Allergy under the age of 2 years (and older for certain categories) Written by: Heidi Ball, Paediatric Dietitian UHL Emma Jordan, Paediatric Dietitian LPT Reviewed and Edited by: Hardeep Singh Bagga, Deputy Head of Medicines Optimisation LC CCG Date written/reviewed: August 2017 Date of next review: August 2019 Approved by LMSG: August 2017 Version: 2.1 1
Contents: 1) COWS MILK PROTEIN ALLERGY (CMPA) - CHILDREN UNDER 2 YEARS 2) Transitioning children (with Cows Milk Protein Allergy) from prescribed Specialist Infant Milk formula (Appendix 1) 3) Leicestershire Nutrition and Dietetic Services: Patient Leaflet (Appendix 2) 2
1. COWS MILK PROTEIN ALLERGY (CMPA) - CHILDREN UNDER 2 YEARS Cow s Milk protein allergy (CMPA) is one of the most common childhood food allergies. It is estimated to affect between 2%-7.5% of babies under 1 year of age (NICE 2015), although most children outgrow it by the age of 5 years. CMPA can cause a range of symptoms, some are immediate (IgE mediated) and some are delayed (Non-IgE mediated) see section 1.1 below. Lactose Intolerance in young infants is rare and CMPA should always be considered as an alternative diagnosis. Lactose intolerance usually occurs as a temporary condition following gastroenteritis. Further information on symptoms and management of Lactose Intolerance can be found on pages 9-10. 1.1 Signs and Symptoms of possible CMPA Symptoms that may be caused by milk allergy and may require a specialist infant formula to be prescribed: IgE mediated Non IgE mediated Pruritus, Erythema, Acute urticarial, Acute angioedema, Nausea/Vomiting, Diarrhoea, Cough/wheeze, Anaphylaxis Pruritus, Erythema, Atopic Eczema, GORD, Loose frequent stool, GOR, Blood/mucus in stool, Abdominal pain, Infantile colic, Constipation Perianal Redness, Abdominal pain, Faltering growth (usually with at least one of the above ), Severe vomiting/diarrhoea/fpies 1.2 Next steps and referral Breast fed infants Breast milk remains the ideal choice for the cow s milk allergic infant. If CMPA symptoms persist in the breast fed infant a maternal exclusion diet i.e. milk free is indicated for a minimum period of 2 weeks. The mother will need a calcium supplement of 1000 milligrams(mg) a day if she follows a milk free diet, after this time whilst breastfeeding, along with Vitamin D 10 micrograms(mcg) daily. The child should be referred to a Paediatric Dietitian. Not breast fed or receiving top up formula feeds For infants who are either not being breast fed or having top up formula feeds a specialist infant formula free from whole cow s milk protein may be required for: The treatment of symptoms where cow s milk allergy is strongly suspected Diagnostic purposes where it should be used for a trial period of time and symptoms reviewed. Parents/Carers should also be given advice on avoidance of cow s milk in solid foods. When to refer Consider referral to secondary or specialist care if any of the following apply (NICE Cow s Milk Protein Allergy in children 2015) Faltering growth with one or more gastrointestinal symptoms One or more acute systemic reactions or severe delayed reactions Significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer. Possible multiple allergies Persisting parental suspicion of food allergy (especially where symptoms are difficult or perplexing) despite lack of supporting history. Symptoms do not respond to a single elimination diet There is confirmed IgE mediated food allergy and/ or concurrent asthma Consider routine referral to primary care paediatric dietetics within 6 months, for infants who are tolerating the new formula well and are not suffering with any of the conditions above. Routine referral is recommended to ensure children are reviewed by a dietitian and parents encouraged to trial milk re-challenge at appropriate intervals, using appropriate methods. 3
1.3 Choice of Cow s Milk Free Formula All specialist infant formulas meet the nutritional requirements of infants under 12 months when breast milk is unavailable. Table 1 lists infant formula currently available (Apr 2017) suitable for the treatment of proven and suspected cow s milk allergy. It includes: Soya formula Acceptable product for children over 6 months age, if tolerated. Based on whole soya protein and so are devoid of any milk proteins. Possible concerns of natural phytoestrogen content in children under 6 months of age (COT report 2003) and possible soya allergy cross reactivity. To be purchased by parents from chemists or supermarkets First choice - Extensively hydrolysed formula Based on hydrolysed protein (usually whey or casein) and are the first line treatment of choice (unless soya tolerated). Contain small traces of residual milk proteins which have the potential of causing symptoms in a small number of highly sensitive patients. Differences in protein source, presence/absence of lactose and degree of protein hydrolysation gives rise to differences in palatability and reactivity i.e. one brand may occasionally be better tolerated than another (patient specific), although as first line, any are suitable (see table 1 & flow chart below, pages 5&7). If an infant does not tolerate the first extensively hydrolysed formula, with symptoms not considered severe, consider trying an alternative extensively hydrolysed formula (see table 1 & flow chart below, pages 5&7). Stage 2 extensively hydrolysed formula contains additional calcium and iron and can be used from 6 months onwards, (not essential). Reserved second choice - Amino acid formula Formula based on amino acids that contain no residual cow s milk proteins. Their use (due to high cost) should be reserved for those patients with severe milk allergy such as previous anaphylaxis, reactivity to breast milk etc or those who require improved nutrient absorption e.g. faltering growth, and those unable to tolerate soya or extensively hydrolysed formula. A standard amino acid formula is suitable as a milk substitute from birth (and after the age of 12 months) A junior amino acid formula (flavoured/unflavoured) is available for those infants with increased requirements. (from 12 months) Note: CHOICE OF INFANT FORMULA SHOULD BE BASED ON CRITERIA OF LEAST LIKELY TO REACT/ RESOLUTION OF SYMPTOMS IN MOST CASES (this may not always be the cheapest product) For any of the above products a change in prescription may be requested if feed is not being taken due to palatability. This should be done by selecting an alternative brand in the same class of product, i.e. do not routinely move to the next step for palatability changes. (see table 1 & flow chart below, pages 5&7) 4
Table 1: Infant formula for proven or suspected cow s milk allergy Formula Soya based formula Wysoy (v&h) Summary of product Whole soya protein based. Not for under 6 months or infants with soya allergy Size of tin Suggested number of tins per month* (up to age 2 years) Cost per 500ml of made up feed ( April 2017 BNF for Children & 13.5% dilution) 430/860g (8 / 3) 79p Should be purchased by patient s parents Extensively hydrolysed formula (ehf) SMA Althera Hydrolysed Whey (contains lactose) 450g 8 1.60 Aptamil Pepti 1 Aptamil Pepti 2 Hydrolysed Whey (contains lactose) 800g 4-5 1.56 1.56 Nutramigen LGG 1 Nutramigen LGG 2 Hydrolysed Casein 400g 9 1.83 1.86 Similac Alimentum Hydrolysed Casein 400g 9 1.48 Amino Acid (AA) based standard formula (RESTRICTED) Neocate LCP (v&h) Nutramigen Puramino (h) Only use for patients meeting the specific criteria 400g 400g 9 12 depending on catch up. 5.30 (15% dilution) 5.07 SMA Alfamino (v) 400g Amino Acid based follow on formula (RESTRICTED Specialist only initiation) 4.31 Neocate Junior (v&h) -Replaces neocate active and advance. Only use from 12 months for patients meeting specific criteria. Please specify flavour as unflavoured, strawberry or vanilla. -ONLY PRESCRIBE IF ADVISED BY DIETITIAN Flavoured/unflavoured 400g tin Dilution as per product instructions or as per dietitian advice. 10 x 400g tins per month 7.60 *figure based on 700ml formula per day. The amount is a GUIDE and some infants may require larger volumes due to increased requirements, catch up growth and/or feeding problems. The Dietitian will send a correspondence either via ICE, fax or post informing the GP of formula choice, continued need for a formula, suggested volumes and also when a formula is no longer needed at each review. If patients routinely requests larger volumes, the amount of wastage and how the feed is being made should be checked and patients should be advised to make up only as needed. Where consideration for vegetarian or halal is required, an indication is given, please note that formulas change regularly, therefore information is correct at time of writing but this may change. v = vegetarian h = halal approved 5
1.4 How much formula should be prescribed and when should prescriptions for specialist formula be stopped / reviewed? 6 monthly checks All infants and children diagnosed with milk allergy should have a review with a Dietitian and/or Physician at least 6 monthly to check. Weight/length (it is extremely important to track growth as fall from centile may signify nutritional deficiency e.g. Vitamin D) Improved tolerance to allergen. Nutritional adequacy of diet. All of the above are important in assessing the need for a continued cow s milk substitute prescription. A prescription may need to be changed as tolerance improves (for example amino acid to extensively hydrolysed, extensively hydrolysed to soya). Prescribing Quantities The amount of formula needed will in general be based on (if exclusively formula fed): Infants < 6 months - (150 200ml/kg) - 2 /3 x 400g tins per week Infants over 6 months (500 900ml per day) - 3 x 400g tins per week If non standard amounts of formula are required, this must be justified by the Dietitian. Infant formula is an important source of energy, protein, calcium, vitamin D and iron and should preferably be continued until the age of 2 years as the main source of milk substitute, in children with cow s milk allergy in order to maintain nutritional adequacy. Exceptions include those infants over 1 year tolerating soya who are eating a mixed diet and taking adequate amounts of fortified carton soya milk with normal weight gain and growth. Infant formula should only continue to be prescribed over the age of 2 years as advised by a dietitian for those infants with multiple allergies and/or poor weight gain, faltering growth and poor variety of solid food or who are on a tube feed. 1.5 Additional minerals and vitamins All infants who are breast fed over 1 month old (on advice of midwife or health visitor) or who either no longer take formula or take less than 500ml/day should take a vitamin preparation containing Vitamin A, D, B & C appropriate for age. This can be purchased in chemists and supermarkets and is also available as part of healthy start programmes (ensure cows milk free). Additional Calcium may also be required when assessed by a dietitian. 6
Leicestershire Nutrition and Dietetic Services FLOW CHART FOR COW S MILK PROTEIN ALLERGY (CMPA) 0-24 months Refer to NICE guidelines (Cows Milk Protein Allergy in Children June 2015) on when to refer to secondary care CMPA symptomatic (Anaphylaxis at presentation?) Is infant breastfed? Advise on avoidance of cow s milk in maternal diet only if symptomatic when exclusively breast fed. Advise mother to follow cow s milk free diet and start calcium & vitamin D supplements. After 4 weeks if infant is still symptomatic, advise mother to resume normal diet and query alternative diagnosis e.g. reflux Is supplementary feeding needed? -check for anaphylaxis, if present see CMPA symptomatic anaphylaxis at presentation (above) Prescribe trial of extensively hydrolysed formula (ehf) (age 0-24 months) OR Soya formula* (if infant is 6 months plus) purchased from chemist/supermarket may also be suitable Avoid if possibility of soya intolerance FIRST LINE choice (Age 0-24 months) Nutramigen 1 LGG (and Nutramigen 2 from 6 months) Casein based, lactose free, probiotics,95%hydrolysed protein OR SMA Althera whey based, contains lactose, 100% hydrolysed protein, less bitter taste (other brands are available, see main guidelines table 1) Symptoms resolved Formula refused Symptoms have not resolved Age 2 years plus See separate Guidance for Transitioning children (with Cows Milk Protein Allergy) from prescribed Specialist Infant Milk formula *1. Continue choice & refer to Community Paediatric Dietitian AND *2. Ensure 6 month review 1.Change casein ehf to whey ehf (or vice versa) OR 2. Change ehf to soya formula (for age six months plus only) OR 3. Change to AA only if refusal due to allergy Prescribe trial of amino acid formula (AA): Neocate LCP OR Puramino OR SMA Alfamino Consider referral to Dietitian Refer to Children s Allergy OR consider other diagnosis 7
2. Use of Specialist Infant Formula over the age of 2 years. Children should be transitioned off formula at around the age of 2 years unless there are medical reasons to continue. Continuation above the age of 2 years should only be on the advice of a dietitian. (see separate Guidance for Transitioning children (with Cows Milk Protein Allergy)from prescribed Specialist Infant Milk formula ) 8
3. LACTOSE INTOLERANCE Symptoms that may be caused by lactose intolerance and require a lactose free formula/milk and lactose free diet: Persistent diarrhoea (particularly following gastroenteritis). Abdominal pain/bloating Offensive acidic stool, peri-anal redness Excessive wind Lactose intolerance usually occurs as a temporary condition following gastroenteritis and a specialist infant formula free from lactose (e.g. SMA LF) or soya formula should be purchased from chemists. It is extremely rare in breast fed infants. As lactose free formula contain whole cows milk protein, they are not suitable for infants who also display symptoms of cows milk allergy (see symptoms of CMPA page 2) as prolonged use of lactose free formula may delay diagnosis. A cow s milk free formula should be used instead as first line treatment. Lactose intolerance can be a symptom of other GI disorders (e.g Coeliac disease), infective diarrhoea (e.g. rotavirus) and this may need investigation at presentation. 9
Leicestershire Nutrition and Dietetic Service Flow Chart for Managing Secondary Lactose Intolerance Has the infant had symptoms such as: Abdominal bloating Increased wind Loose stools Usually occurs following an infectious gastrointestinal illness Note: Lactose intolerance in young infants is rare and cow s milk protein allergy should always be considered as an alternative diagnosis >12 months of age Yes Advise Lactose free full fat milk (can be purchased at supermarkets) Use in conjunction with milk free diet 0-12 months of age Yes Bottle fed Breast fed Advise 3 week trial (purchased from chemist) of either: SMA LF (v&h) or Aptamil Lactose free or Enfamil O-LAC If weaned, use in conjunction with a milk free diet Lactose intolerance in exclusively breastfed infants is extremely rare If symptoms are present, consider cow s milk protein allergy (See CMPA flow chart for advice) or see text The mother may benefit from referral to a breastfeeding counsellor e.g. unsettled infants breast feeding too frequently Review after 2-3 weeks have symptoms improved? Yes No Consider alternative diagnosis e.g. Cow s milk protein allergy, other GI disease Continue lactose free formula for up to 8 weeks to allow resolution of symptoms then advise parent to slowly start to re-introduce formula / milk into diet Yes Have symptoms resolved on commencement of standard infant formula / milk? Yes No Return to lactose free formula and refer to community paediatric Dietitian or secondary care No further action required 10
Version control Version Section Description of amendments Date Author/amended by 1.1 All Infasoy removed SMA Alfamino added Nutramigen AA name changed to Nutramigen Puramino July 2015 Christine Grantham Senior Dietitian - Prescribing 1.2 All Nutramigen Lipil 1 & 2 names changed to Nutramigen LGG 1 & 2 Prices amended as per BNF for Children Jan 2016 Suggested volumes for infants amended 2.1 All Format/editing changes to main guidance and flowcharts, with the additional reference to transitioning of children over the age of 2 years. Prices amended as per BNF for Children Apr 2017. Suggested volumes for infants amended. Jan 2016 August 2017 Heidi Ball Paediatric Dietitian UHL Heidi Ball Paediatric Dietitian UHL Emma Jordan, Paediatric Dietitian LPT Hardeep Singh Bagga Deputy Head of Meds Opt LC CCG 11
APPENDIX 1 Transitioning children (with Cows Milk Protein Allergy) from prescribed Specialist Infant Milk formula Guidance scope: Review the prescribing of specialist infant formula for children over the age of 2 years. Below two years of age: An infant formula free from cow s milk should continue to be prescribed up to the age of 2 years for all children with proven milk allergy (or for diagnostic trial purposes) to ensure an adequate intake of energy, protein and important nutrients commonly found to be low in cow s milk exclusion diets such as Calcium, Vitamin A and D, Riboflavin (B2) and Iron. HOWEVER children regularly ingesting soya products such as soya milk and soya desserts can wean from infant formula onto calcium supplemented soya milk, (preferably Soya Junior Drink) from 1 year. Above two years of age: After the age of 2 years this guidance can be used for transitioning a child to stop prescribing (Section 1) or continue prescribing (Section 2). 1. A gradual transition from specialist infant formula to an alternative milk drink should occur over 0 6 months from 2 years of age. 2. Parents should be given the leaflet Moving on from my allergen free formula milk what next which gives information on changing from a prescribed formula to other products. 3. Parents requesting a continued prescription after a 6 month transition period without a dietetic need should be briefed on self-funding. Alternative milk drink examples (to purchase) Soya milk (carton) if soya is tolerated (some children with cow s milk allergy react to soya; (this is usually GI symptoms such as diarrhoea/pain) Other alternative milk drinks based on Oat, Coconut, Almond, Hazelnut. Caution when transitioning SECTION 1 Transitioning a child to stop prescribing Choice will be influenced by taste, availability and tolerance to ingredients. Children with a proven nut allergy should avoid nut based drinks. Rice Milk is not suitable as a main drink under the age of four and half years due to the natural arsenic content. These alternative milk drinks are not nutritionally the same as infant formula/cow s milk. They are lower in calories, contain negligible protein, and vary in their Calcium and Vitamin content depending on brand. Therefore it is important to check during the transition period that: A brand fortified with added Calcium is used All children using an alternative milk drink should take daily multivitamin drops/syrup A protein source is being included daily in the diet (meat/fish/pulses/nut spreads) Extra calories are encouraged by being generous with fats (dairy free spreads/frying/) and additional snacks. Weight and length is monitored at least once in the 6 months following stopping formula prescription Dental care should be advised and bottle drinking discouraged as most alternative milk drinks contain sugar 12
Further details on this can be found in the parent leaflet Moving on from my allergen free infant formula what next. Children with cow s milk allergy using alternative milk drinks with weight loss, faltering growth or nutritional concerns or deficiencies should be referred to a paediatric Dietitian for advice. SECTION 2 Continuing prescribing Some children will need to continue their prescription for allergen free specialist infant formula after the age of 2 years. All children in this category should be under the care of a dietitian with correspondence to the GP giving: Reasons for needing continued prescribing Quantities to be prescribed. (the amount may vary depending on solid food intake, but should not be lower than 300ml and not above 900ml per day. Therefore the maximum prescription for infants remaining on a specialist formula over the age of 2 should not exceed 3 x 400g tins per week, with 2 x 400g tins per week being the norm) Children lost to follow up due to a failed attendance should have their prescription suspended, until a review of need is completed (this can be done by the GP). A subsequent referral to paediatric dietetics to be made if the GP feels there is grounds for continued use. Children requiring formula after the age of 2 years are likely to fall into two categories: 1. Multiple Food Allergy (unable to tolerate other substitute/higher nutritional risk) 2. Faltering growth/feeding Problems/Nutritional Deficiencies Where possible the dietitian should select the most appropriate least expensive product for that child, for example a prescription for Amino Acid Formula will only be advised where an extensively hydrolysed formula cannot be used. 13
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Useful contact numbers: Where uncertainty exists or a practice would like to check if the patient is still under the care of UHL or LPT dietetics, the following phone numbers can be used: Nutrition and Dietetic Service LPT - 0116 2227170 Nutrition and Dietetic Service UHL LRI - 0116 2585400 Paediatric Allergy Service UHL LRI - 0116 2586694 Please check which service the patient was under previously and contact the appropriate service Version control Version Section Description of amendments Date Author/amended by 1.1 All New guidance August 2017 Heidi Ball Paediatric Dietitian UHL Emma Jordan, Paediatric Dietitian LPT Hardeep Singh Bagga Deputy Head of Meds Optimisation LC CCG 15
APPENDIX 2 Leicestershire Nutrition and Dietetic Services MOVING ON FROM ALLERGEN FREE INFANT FORMULA WHAT NEXT? A guide for parents of children with Cow s Milk Allergy over the age of 2 years Up to the age of 2 years prescribed specialist formula milk is an important substitute for cow s milk, as it provides a high percentage of your child s nutrients, which are important for good growth and weight gain. However, as your child gets older and eats a greater quantity and variety of solid foods, most nutrition can be provided from foods rather than milk (with the exception of Calcium). After the age of 2 years your child s specialist formula milk should begin to be switched to an alternative milk drink, unless your child s dietitian has advised otherwise. You may already be using some of these milk alternatives in cooking and they can also be used as a drink instead of formula. What is an alternative milk drink? This is the name given to ready to drink cartons of milk substitute found in supermarkets, sold as a cow s milk replacement. They are called drinks rather than milk as they do not contain the same nutrients as milk. They are made from water and usually a plant source such as Soya, Coconut, Almond, Hazelnut, Oats or Rice, so they are suitable for cow s milk allergy (Goats milk and Lactose free milks are unsuitable). Many are sweetened with sugar/fruit juice so it is important to look after your child s teeth by giving drinks from a beaker, rather than a bottle and ensuring teeth are cleaned by brushing twice daily. It is also recommended to have regular dental check-ups. Which alternative milk drink should I use? PARENT/CARER LEAFLET If your child can tolerate soya, soya milks are the best choice nutritionally, as they contain more calories and protein. If soya is not tolerated your choice will depend on taste and availability. Also consider the following: Always choose an alternative milk drink that contains added calcium. Organic milk substitutes do not contain added calcium. Rice milk is unsuitable as a main drink for children under the age of 4 ½ years due to its natural arsenic content. Alternative milk drinks are readily available in supermarkets and should be purchased by parents/carers. I notice that alternative milk drinks do not contain protein, will my child still grow? Alternative milk drinks (except soya milk) are low in protein and fat which is why they are rarely suitable for children under the age of 2 years or when there is multiple food allergy. Offer protein rich foods at two meals a day for example, meat, fish, eggs or pulses (peas and beans), nut spreads Use dairy free spreads generously, add regular oil (e.g. frying) Give extra snacks if your child seems hungry or not gaining weight. 16
My child does not like the taste of the new milk drink, he prefers formula Children may need to be offered a new taste many times before deciding if they like it. It is recommended to transition to an alternative milk drink over a couple of months. Start by trying the new drink on cereals or in cooking and then replace 1 ounce (30ml) of formula with the new drink every few days. If your child continues to dislike the taste, try a different brand or type. Your GP will continue to prescribe your child s specialist formula for up to 6 months after the age of 2 years, whilst you transition to an alternative milk drink. After 6 months (or sooner if the transition is achieved sooner) your GP will not be able to prescribe the specialist formula. The only exception is if there is a valid medical reason or on the advice from a dietitian. Taste preference is not considered a valid reason to continue prescribing after 6 months. Can my child be allergic to the new milk drink? Some children with milk allergy can get similar symptoms with soya (usually those with tummy problems), but this is usually at a younger age. If your child continues to get symptoms with alternative milk drinks try another substitute (or discuss with your dietitian). Alternative milk drinks based on nuts e.g. Almond, Hazelnut (Coconut is not a nut) should be avoided in children with a proven nut allergy (this should be diagnosed at the hospital allergy clinic). Does my child need any Vitamin or Mineral supplements? Children taking alternative milk drinks instead of infant formula should routinely take a multivitamin containing Vitamins D, A and riboflavin to ensure adequate intake. For young children multivitamin drops and syrups are readily available to purchase in supermarkets and Chemists (ask a Pharmacist if advice is needed). Healthy start vitamins are also available as part of the healthy start programme. If less than 300ml of alternative milk drink is taken (or you are using a drink that is NOT calcium fortified) it may be recommended your child also takes a calcium supplement. Discuss this with your Doctor, Dietician or refer to leaflet is my child getting enough calcium (available from September 2017). My child has multiple food allergies and has limited food choices, should I continue with my allergy infant formula? Your dietitian will advise your GP to continue to prescribing for your infant formula if there is a medical need. This includes having multiple food allergies, feeding problems or difficulties in achieving nutritional adequacy from solid foods, especially if protein sources are limited. Can t I just put my child back on ordinary cow s milk rather than using an alternative milk drink? The majority of children outgrow their milk allergy by the age of 3 years. If you have not had an appointment with a dietitian in the last 6 months (or would like to retry cow s milk) ask your GP to be referred to the dietitian who will discuss a safe way to try milk back into your child s diet, using a milk reintroduction ladder (this starts with giving traces of a biscuit containing milk as an ingredient). Do not try milk reintroduction without professional advice if your child has had a reaction to cow s milk in the past that caused rash, cough, wheeze, severe vomiting/diarrhoea. However, if your child is already tolerating a full portion of yoghurt or cheese then small amounts of fresh milk can be tried. Does my child HAVE to take a milk alternative, he prefers cereals dry? If your child eats good quantities of a variety of foods from different food groups (meat/fish/pulses, cereals/bread, fruits/vegetables) and is growing and gaining weight well, an alternative to milk is not essential, BUT YOUR CHILD WILL NEED A CALCIUM SUPPLEMENT and should take multivitamins. Discuss this with your Doctor or Dietitian, or refer to leaflet is my child getting enough calcium (available from September 2017). He/she may also need extra snacks. 17
Version control Version Section Description of amendments Date Author/amended by 1.1 All New guidance August Heidi Ball 2017 Paediatric Dietitian UHL Emma Jordan, Paediatric Dietitian LPT 18