At the Paediatric Gut Investigation Clinic we know that proper nutrition is an essential element in the growth of children and young adults. A healthy diet should include a wide variety of food from all of the food groups in order for the body to function correctly. However a gastrointestinal disorder can limit your child’s ability to have this variety. This can be caused by a poor appetite, food intolerances, allergies, food sensitivities, and others. If this happens our team will provide you with a variety of ways to ensure that your child has a well balanced diet. Below are the frequently asked questions about nutrition and the role of a dietitian.
What is a dietitian?
“Dietitians are the only qualified health professionals that assess, diagnose and treat dietary and nutritional problems at an individual and wider public-health level. They work with both healthy and sick people. Uniquely, dietitians use the most up-to-date public health and scientific research on food, health and disease which they translate into practical guidance to enable people to make appropriate lifestyle and food choices.
Dietitians are the only nutrition professionals to be regulated by law, and are governed by an ethical code to ensure that they always work to the highest standard.”
British Dietetic Association https://www.bda.uk.com/improvinghealth/yourhealth/dietitians
Why is nutrition important in children?
Nutrition is a vital component to supporting the growth and development of all children. Achieving the correct nutritional intake ensures children meet their full potential which is the target for parents and health professionals alike.
An increasing body of international evidence supports the theory that what and how much we feed our children not only effects their current health but has the potential to profoundly impact on their long term health as adults. Because of this increasing attention is being paid to the nutrition of both and well and unwell children to ensure we provide the correct balance of nutrients (i.e. avoiding excess and insufficient intakes).
Some conditions such as food allergy and GI conditions can have a significant impact on the foods and diets of children and therefore the involvement of a dietitian is key.
What can your dietitian provide / how can we help?
Assessment of growth
Assessment of current intake
Practical advice on special diets
Practical advice on feeding behavioural modification
Provision of reliable and trustworthy written literature
On going support and reviews
Why monitor growth?
Growth is a vital and very reliable overall marker of health in infants and children. This is why we always start our appointments with an assessment of growth and address this first. Infants and children seen in our clinic will always have their weight and height checked (other anthropometric measurements such as head circumference, mid arm circumference, BMI etc. as clinically indicated) as an essential part of their review.
Just as important as accurate measurements is ensuring the correct interpretation of these in the context of growth and development. We have significant experience and expertise in this area and we will take the time to review growth and nutritional status carefully and thoroughly.
If concerns around growth exist or become apparent there are a variety of interventions we can advise to successful and safely correct this.
What areas do we specialise in?
Food allergy appears to be on the increase in the UK. Management is often simply avoidance of the foods or food groups that have been identified as causing an issue. However balancing the diet within these restrictions and practically ensuring the intake is free from necessary allergens is not always so simple. Food allergies have a considerable impact on the life of the child and their parents/caregivers and have shown to be associated with high levels of anxiety in affected individuals
Children seen in our clinic will have their diets assessed to ensure they are adequate and well balanced. We might suggest alterations within the diet, use of specialist supplement products and use of specialist infant formulas. We will also advise on the timings and practical aspects of safe and appropriate challenges to ensure restrictions are regularly reviewed and practical advice like how to read and interpret food labels. Food allergy is a fast evolving area. We follow the most recent European recommendations as well as keeping a close eye on the latest research to ensure the advice and support we give is the most up to date.
Below are the most common foods to cause allergic reactions or hypersensitivity.
Cows milk protein allergy
Cows’ milk protein allergy (CMPA) is an immune-mediated allergic response to proteins in milk. It is one of the most common childhood food allergies in the developed world, with the highest prevalence during the first year of life. Strict exclusion of cows’ milk protein from the child’s diet (or maternal diet for exclusively breastfed babies) is currently the safest strategy for managing confirmed cows’ milk protein allergy (Ref 1). CMPA commonly resolves by age 6 years but due to the significance of this food group for calories and nutrients it is essential to involve a dietitian in the management. As well as the restrictions, the timings and types of milk protein challenge are important to re assess tolerance with time.
There are two types of soya allergy: ‘IgE mediated’ (where the allergic reaction is immediate) and ‘non-IgE mediated’ (where the allergic reaction is delayed). It is much rarer than milk allergy but often co exists if the child also has a milk allergy. Strict avoidance is again necessary with a planned systemic re introduction in a timely way to review status and possible tolerance development. Practically one of the biggest hurdles with soya exclusion is the sheer number of basic foods that contain soya as an ingredient such as bread, pasta and many commercially processed foods.
Primary nut allergy affects over 2% of children and 0.5% of adults in the UK (Ref 2) It often presents in the first 5 years of life and infants with other allergic conditions such as severe eczema and/or egg allergy have a higher risk of peanut allergy. Nut allergy is likely to be long-lived and nut avoidance advice is the cornerstone of management. Ensuring parents understand labelling if key to education to ensure reduced risk of a reaction. Nuts are good sources of several minerals so having knowledge of alternative sources is important.
Wheat allergy/ sensitivity/ coeliac disease
True wheat allergy is thought to be very rare (estimated 0.4%) but hypersensitivity leading to symptoms is quite commonly reported and seen in clinical practice. For information about coeliac disease please see separate section. It is important to distinguish between wheat allergy, coeliac disease and non-allergic hypersensitivity for your child and your gastroenterologist can clarify this for you. Depending on the condition the severity of the restriction will be different with most care required for those with a coeliac diagnosis.
Wheat restriction limits major staple carbohydrate sources which in turn can limited a selection of nutrient dense fortified foods like breakfast cereals.
Prevalence of hen’s egg allergies is thought to be about 2% (Ref 3,4). Management again centres around education of avoidance and replacement options. Most children outgrow their egg allergy but prevalence data is variable. Eggs are nutrient dense foods and alternative foods to ensure a complete diet are important to include.
Difficult feeding behaviours
Feeding issues or fussy eating is very common in children. Whilst it is rare for this to result in growth failure it can leave the diet unbalanced as well as be a source of significant family stress. We deal with a variety of different presentations such as difficulty to progress with texture and solids, food refusal, self-restricted intakes and aversive behaviours. We will assess the degree of the difficult eating behaviours using several well recognised tools and provide bespoke advice of how to progress based on these. A detailed assessment of the intake is often very useful to identify the nutritional impact of difficult feeding behaviours and will also be undertaken. We can provide a variety of different proven nutritional and behavioural strategies to effectively and efficiently advance children and try to improve the situation.
Sub optimal growth is a concern for both health care professionals and parents. This commonly occurs as a result of a medical condition and can be addressed whilst investigations to identify an issue are continuing and once a condition has been identified and medical treatment begins. Ideally sub optimal growth should be managed and treated as soon as it passes certain cut offs and we can help to assess and advise on this. We can help and advise on the best and most effective nutritional changes e.g. specialist infant formulas, supplementation with macro nutrient specific supplements or the use of more complete nutritional products designed and proven to most appropriately support catch up growth.
Coeliac disease is a lifelong condition effecting 1% of the UK population. It is an inflammatory condition of the small intestine caused by a child’s intolerance to gluten, which is in cereals. Once it has been diagnosed a change in the fundamental diet is essential to establish. This can be daunting and difficult to practically implicate. We can help provide all the information required to successfully and quickly change the diet whilst ensuring it is nutritionally adequate and meets the needs of the child. We can provide written advice, signpost to the leading information and support sites and advise on how best to discuss the new diet with your child.
Recurrent abdominal pain
Recurrent abdominal pain requires investigation by a gastroenterologist. The impact of this however is often a reduced appetite which in turn can effect growth. Several nutritional strategies to both address the impact of the symptoms and investigate possible nutritional causes can be advised. We can help to advice on how best to establish these, the timing and nature of trial restrictions and possible nutritional interventions.
Your gastroenterologist may have diagnosed a condition called toddler diarrhoea. This is very common in children under 5 and in many cases has no significant impact on a child’s growth. However, there are several nutritional triggers that might be causing the symptoms or contributing to them. Several strategies (inclusions and exclusions) can be used often very successfully to reduce the symptoms and control the situation. We can assess the current intake to look for these likely triggers then suggest the practical ways of introducing some of the interventions, all whilst ensuring the child has optimal nutritional intake.
Several different types of lactose interlace exist. Lactose intolerance is very different from cow’s milk protein allergy but they are commonly confused. Your gastroenterologist can confirm for you with the most appropriate investigations if your child has a form of lactose intolerance. If this is identified we can help to assess the current diet to ensure it is nutritionally adequate. We can provide reliable sources of information to ensure the correct restriction is maintained and advise on the most appropriate forms of nutritional supplementation as well as the best foods to include where possible.
- Nice guidance Milk allergy 2014
- Stiefel1, K. Anagnostou, R. J. Boyle, N. Brathwaite4, P. Ewan, A. T. Fox, P. Huber , D. Luyt, S. J. Till4, C. Venter and A. T. Clark. BSACI guideline for the diagnosis and management of peanut and tree nut allergy 2017
- Nwaru BI, Hickstein L, Panesar SS, Roberts G, Muraro A, Sheikh A, On behalf of The EAACI Food Allergy &Anaphylaxis Guidelines Group. Prevalence of common food allergies in Europe: a systematic review and metaanalysis. Allergy 2014; 69:992-1007.
- Xepapadaki P, Fiocchi A, Grabenhenrich L et al. Incidence and natural history of hen’s egg allergy in the first 2 years of life – the EuroPrevall birth cohort study. Allergy 2016; 71:350-7.