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Growing up with CMPA
Complementary Feeding for CMPA Infants
The WHO and other experts suggest, complementary feeding (CF) is the process of starting other foods and liquids when breastmilk alone is no longer sufficient to meet the nutritional requirements of infants (WHO 2002; Dewey 2003 (Book); ESFA 2009; Fewtrell et al 2017). The WHO recommend exclusive breastfeeding for 6 months, followed by the introduction of CF alongside breastfeeding (WHO 2002).
Complementary foods are considered necessary for both nutritional and developmental reasons, and are an important step in the transition from milk feeding only, to the addition of family foods (Fewtrell et al 2017). Furthermore, an energy gap develops, usually beyond 6 months of age, which needs to be covered by complementary foods. In infants with an established food allergy such as cow’s milk protein allergy a replacement hypoallergenic formula also supports the ‘’energy gap’’. This is represented in Figure 1., showing the energy provided by breastmilk and when the energy gap starts to develop.
Energy provision
from breastmilk and
the energy gap
In infants with CMPA, there is no evidence that delaying the introduction of other potentially allergenic foods (e.g., wheat, soya, egg, fish, nuts) will prevent the development of additional food allergies. In fact, evidence is building that early, rather than delayed, introduction to these foods could be beneficial (Greer et al 2019).
In infants with established CMPA, CF should therefore begin as for an infant without a food allergy (around 4-6 months but not before 4 months). It has been suggested in the UK guidance that “These children may benefit from the earlier introduction of cooked egg and then peanut alongside other solids, from around 4 months of age” but not before 4 months! (BSACI & BDA 2018). While some experts suggest that other allergens should be introduced one at a time (ASCIA, 2020).
Which foods and
food groups should
be introduced?
Small amounts of different food groups e.g., vegetables, fruits, starchy foods, protein sources without added salt or sugar should be included (BSACI & BDA. 2018) – (see table for some examples – adapted from the WHO 2009).
| Food Groups | Nutrient Provided | Food Example |
|---|---|---|
| Local Staple Carbohydrate | Energy | Cereals (rice, maize, wheat), cassava, sweet potato, for babies with CMPA foods should be dairy protein free! |
| Foods from animal origin or vegetarians/vegan options* | Protein, energy, iron, zinc | Red meat, chicken, fish, eggs, beans, peas, lentils, nuts (ground and tree), seeds |
| Dairy, or dairy replacement when CMPA | Protein, energy, vitamins, minerals | Dairy products, fortified cereals, or non-diary options and replacement hypoallergenic formula when CMPA |
| Fruits and vegetables | Carotenes, folate, vitamin C, some minerals and trace elements | Carrots, butternut, papaya, spinach, broccoli (not limited to these) |
| Fats & oils | Energy, essential fatty acids, fat soluble vitamins | Vegetable and seed oils, margarine, butter, dairy free spreads when CMPA |
- Common allergy causing foods can be introduced one at a time. This is because infants with CMPA have a 50% higher risk of developing other allergies (ASCIA, 2020). This also makes it easier to identify a problem food if an allergic reaction does occur. Once introduced and tolerated, these foods should be regularly included the infants’ diet (ASCIA, 2020).
- In the UK they suggested eczema should be well-controlled before introducing allergens into the diet i.e., cleared prior to introducing allergenic foods (to help detect if tolerant) (BSACI & BDA 2018).
The more diverse the diet the better! An increase in the diversity of the diet was associated with better growth indices in young children (Ruel MT. 2003; Venter et al 2020) and may be associated with reduced allergic outcomes (Venter et al 2020).
In infants with CMPA there may be commercial offerings that are free-from the implicated allergen offering parents more choice, as well as reassurance with food introductions and will enable diet diversity.
A variety of different foods and flavours should be introduced while avoiding cow’s milk/dairy proteins. During the early weaning stage, breastmilk or hypoallergenic formula will contribute a major part of the nutrients needed by the infant and can also be used in recipes.
Importance of
Reading Product
Labels
Since 2005 the European Union has 12 foods, including dairy/milk, that are required to be presented as content on the label of all processed or prepackaged foods (Fiocchi et al., 2010 WAO).
Similar legislation exists in the US, where the Food Allergen Labelling and Consumer Protection Act proposed that all milk products require an ingredient statement.
Dietetic intervention commonly includes teaching families how to read food labels, to help mitigate risk of cross contamination (Wright et al., 2022). This will include informing parents/caregivers to check food labels thoroughly every time they shop – even if they have bought a product before, as recipes sometimes change (Anaphylaxis campaign UK- Factsheet 2021).
Some Additional
Questions around
Complementary
Fedding
Are infants and children with CMPA at a greater risk of developing feeding issues?
Yes, behavioral feeding issues are more common in infants and young children with a diagnosis of CMPA due to fear of a repeated reaction (especially when severe CMPA) (Food Allergy Canada. FAQ for families - factsheet. (Online). 2019).
Should Complementary Feeding stop if the child is ill?
During illness HCP commonly encourage that the child is given his/her favorite foods as well as small frequent meals, but CF should not be stopped. Furthermore, during illness encourage extra fluids, including more frequent breastfeeds or hypoallergenic formula (when formula-fed) (WHO. (Online). 2009).
Do children with CMPA need additional vitamins and minerals?
Infants and children with CMPA, especially those with gastrointestinal issues, appear to be at a higher risk of deficits when not consuming a hypoallergenic formula (Meyer et al. Clin Transl Allergy. 2014). While unfortified complementary foods that are 100% plant-based may not provide sufficient amounts of certain key nutrients (eg. iron, zinc, vitamin B6 and calcium) (Dewey K. (Book). 2003; WHO (Online) 2009). Use of fortified cereals can boost the intake of these nutrients, which is especially important in those following vegetarian and vegan diets.
Any specific needs for infants/children following a vegan or vegetarian diet?
Infants and children with CMPA who are not breastfed should receive a replacement hypoallergenic formula, which is nutritionally complete. Vegan diets require dietetic supervision - and for those following a vegan or vegetarian diet, careful attention should be paid to the adequacy of vitamins B12 and vitamin D, iron, zinc, folate, omega-3 fatty acids (especially DHA), protein and calcium, and ensure adequate energy in provided (Fewtrell M, et al. JPGN. 2017; Baldassarre ME, et al. J Environ Res Public Health. 2020).
