front of their peers. With the life-expectancy of CF rising (now a mean of 38 years), dietitians are now increasingly incorporating bone and heart health considerations into their dietary advice. The monitoring of children on long-term


Nutricia Paediatric Nutrition and Allergy Study Day | Event Report Moving towards ‘curative nutrition’ in allergy:


home enteral feeding lacks a strong evidence base, but best practice is emerging: Alder Hey Children’s Hospital’s Head of Dietetics, Ruth Watling covered the considerable challenges in supporting and monitoring our growing population of children living at home on enteral feeds. Her focus was children who are likely to be on long-term if not lifelong tube feeding – who are mainly children living with neurodisabilities. It is recommended that these children have their weight and height monitored every three to six months.7


However, it is clear that


many dietietic departments are falling short of this. The reasons for this are numerous – studies have questioned the acceptability of using standard growth reference data for these children.8, 9, 10 Moreover, measurements of weight and heights can be problematic in immobile children, with special equipment such as hoists not always available. Acceptable alternatives to height measuring are upper arm length, tibial length and knee height in children up to 12 years old with cerebral palsy.11


New


data has recently been published for the use of skinfold thicknesses in estimating body fat in cerebral palsy.12


These measures may make regular


monitoring more achievable, with school and other community nursing practitioners ideally placed to help with these measurements. Annual or six monthly biochemistry monitoring is ideal,13, 14 especially for those with low intakes of micronutrients, as cases of vitamin deficiency can occur.15


It is again clear that this is not routinely


carried out. ‘Feeding and Nutrition in Children with Neurodevelopmental Disability’ is recommended reading for dietitians working in the field.16 In the absence of strong evidence for


secondary prevention of food allergy in infants, dietary introduction of allergenic foods should not be delayed. Paediatric Dietitian Dr Rosan Meyer provided an overview of current consensus on weaning the allergic child. Once a food allergy is identified in an infant, dietetic support is key to helping parents successfully and safely eliminate this allergen from their diet. Consensus as to the best age to introduce solids is four to six months,17


which,


despite the UK guidelines to wait until six months, is still the usual weaning practice in the UK.18


In 2008,


US consensus was changed to align with the European guidelines, to recognise that there was no evidence to delay the introduction of egg, dairy, peanut, tree nuts, and soya in any children.


Erika Isolauri, Professor of Paediatrics at the University of Turku, Finland, and Keynote Speaker, described emerging areas of interest in allergy nutrition. Poor growth in allergy is most likely if the symptoms have an early onset, the reaction is severe, there are multiple allergies or there is concurrent inflammation. Increased gut barrier permeability, caused by inflammation has been observed in children with eczema, causing some gut dysfunction, and increased antigen load. Aberrant microbiota in the gut plays a role in this gut inflammation, and is under more investigation. She pointed out that although allergen elimination is the appropriate treatment of choice for an allergic child, to alleviate symptoms, it does not cure the problem. She hypothesised that different foods contain protective factors, and suggested we might be moving towards using this ‘curative nutrition’. For example, appropriate probiotics may have a role in degrading antigens, reducing gut inflammation, decreasing gut permeability and balancing gut microbiota. Omega 3 fatty acids may also have a role in reducing inflammation and increasing the adherence of probiotics. The link between food allergy and eczema


should not be underestimated: Professor Alan Irvine, Paediatric Dermatologist for Our Lady’s Children’s Hospital in Crumlin, Ireland, reported that around 30 per cent of children with eczema experience reactions to foods. NICE guidelines recommend a six to eight-week trial of of an amino acid formula or other hypoallergenic formula in infants under six months with eczema, followed by, once the skin is clear, food challenges. It is important to note that reactions may take five to seven days to appear – in double blind food challenges in 106 children with severe to moderate eczema, 57 had food reactions; 12 per cent of these were delayed reactions. Gut allergy is increasingly presenting as a


multi-system disorder: Great Ormond Street’s Paediatric Gastroenterologist Dr Neil Shah has found that, in a group of 437 GOSH patients, extra- intestinal manifestations of food allergy were common – mouth ulceration (39%), poor sleep (34%), headaches and dizziness (23%), fatigues and lethargy (53%), night sweats (35%), bed wetting (18%), joint pain or hypermobility (36%). The proportion of referrals with multisystem involvement (3 or more body systems) that they see had markedly increased – from 20 per cent in 1998-2002, to 54 per cent in 2004-8. The reason for this increase is not clear, but the autonomic nervous system appears to be the body system link. See Figure 1 for clues to gut symptoms that can be caused by allergy.


Figure 1: Gut Symptoms


Caused by Allergy • Functional gut pain • Infants with feeding difficulties • Effortless vomiting • Failure to thrive • Colic • Medication resistant reflux • Early onset constipation (particularly when breast fed)


• Normal stools yet straining • Proctitis • Painful defecation, and children regularly standing on their tip-toes for no apparent reason (which helps them to squeeze their sphincter).


This article, reviewing the 11th Annual Nutricia Paediatric Nutrition and Allergy Study Day, was supported by an Educational Grant from Nutricia Ltd.


References: 1. Neal EG, et al (2009). A randomized trial of classical and medium-chain triglyceride ketogenic diets in the treatment of childhood epilepsy. Epilepsia.; 50(5): 1109-17. 2. Kossoff EH, et al (2009). Optimal clinical management of children receiving the ketogenic diet: recommendations of the International Ketogenic Diet Study Group. Epilepsia. 50(2):304-17. 3. Bayol SA et al (2009). Evidence that a maternal "junk food" diet during pregnancy and lactation can reduce muscle force in offspring. Eur J Nutr.; 48(1): 62-5. 4. Maier AS, et al (2008). Breastfeeding and experience with variety early in weaning increase infants' acceptance of new foods for up to two months. Clin Nutr.; 27(6): 849-57. 5. Coulthard H et al (2009). Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age. Matern Child Nutr.; 5(1): 75-85. 6. Poustie VJ et al (2006). Oral protein energy supplements for children with cystic fibrosis: CALICO multicentre randomised controlled trial. BMJ.; 332(7542): 632-6. 7. NHS Quality Scotland (2007). Caring for children and young people in the community receiving enteral tube feeding. (Enteral Tube Feeding Best Practice Statement). Accessed online: http://www.nhshealthquality.org/nhsqis/3686.html 8. Sullivan PB, et al (2006). Gastrostomy feeding in cerebral palsy: too much of a good thing? Dev Med Child Neurol.; 48(11): 877-82. 9. Krick J, et al (1996). Pattern of growth in children with cerebral palsy. J Am Diet Assoc.; 96(7): 680-5. 10. Day SM, et al (2007). Growth patterns in a population of children and adolescents with cerebral palsy. Dev Med Child Neurol.; 49(3): 167-71. 11. Stevenson RD (1995). Use of segmental measures to estimate stature in children with cerebral palsy. Arch Pediatr Adolesc Med.; 149(6): 658-62. 12. Gurka MJ, et al (2010). Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy. Dev Med Child Neurol.; 52(2): e35-41. 13. NHS Quality Scotland (2007). Caring for children and young people in the community receiving enteral tube feeding. (Enteral Tube Feeding Best Practice Statement). Accessed online: http://www.nhshealthquality.org/nhsqis/3686.html 14. Braegger C, et al (2010) Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr.; 51(1): 110-22. 15. Gorman SR (2002). Scarcity in the midst of plenty: enteral tube feeding complicated by scurvy. J Pediatr Gastroenterol Nutr.; 35(1): 93-5. 16. Sullivan PB [ed] (2009). Feeding and Nutrition in Children with Neurodevelopmental Disability. MacKIeith Press. 17. Agostoni CJ (2008). Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. Pediatr Gastroenterol Nutr.; 46(1): 99-110. 18. Department of Health [UK] (2005) Infant Feeding Survey. Accessed online: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/infant-feeding-survey/infant-feeding-survey-2005 19. Frank R, et al (2008). Effects of Early Nutritional Intervention on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics; 121: 183-191. 20. Isolauri E, et al (1998). Elimination diet in cows’ milk allergy: risk for impaired growth in young children. J Pediatr.; 132(6): 1004-9. 21. Breuer K (2004). Late eczematous reactions to food in children with atopic dermatitis. Clin Exp Allergy.; 34(5):817-24.


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