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NEW FOOD GUIDELINES ISSUED - MARKED INCREASE IN CHILDHOOD FOOD ALLERGIES CITED

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by Julie Silver, M.D., and Linda Cozzens, M.D.

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Three generations of McAllister women sat in their pediatrician’s exam room: the skilled and knowledgeable grandmother, the less experienced but well read mother, and much-loved 2-month-old Megan. Clearly they had an agenda, and it soon became apparent as Maureen, Megan’s grandmother, the proud matriarch of the family whose family had come to America from Ireland more than 70 years ago, spoke: “I started my seven babies on cereal when they were two weeks old. All of my children are strong and healthy. What is this nonsense about waiting to feed this starving baby?” Kathleen, Megan’s mother, interjected, “I have read that I should wait until Megan is a few months old before starting solid foods, and this is very upsetting to my mother. What are the guidelines and why should I wait?”

The new guidelines When and what to feed babies is an evolving science, and the guidelines are frequently changing as we learn more about infants’ nutritional requirements, how to best establish healthy eating habits, and how to prevent food allergies. To help alleviate some of the confusion and to provide a list of recommendations based on the latest research, the American Academy of Pediatrics (AAP) recently released the fifth edition of its Pediatric Nutrition Handbook. In the new book, there are a number of changes; however, its predominately new focus is on the current recommendations that pertain to preventing food allergies in children. Most doctors, as well as many parents, have observed that the incidence of food allergies seems to be increasing. Dr. Frank Twarog, an associate clinical professor at Harvard Medical School, who is on the medical staff at Children’s Hospital in Boston, observes: “Food allergy is not a reportable condition, so it’s hard to know if it’s on the rise, but yes, there does seem to be an increased prevalence.” Dr. Twarog’s Harvard colleague, Dr. Linda Schneider, director of the Food Allergy Clinic at Children’s Hospital in Boston, concurs that there has been an increase in the incidence of food allergies, which has paralleled the increase in allergies in general. “No one really knows why, though we postulate that it may be related to increased exposure. For example, 50 years ago, it was less common to consume the amount of peanut butter that people consume now. In addition, there are many manufactured baked goods, topical skin care products, and other products that have definitely increased exposures to some of these food items.” Although some children outgrow food allergies, a significant number do not. Dr. Schneider notes: “Food allergies have a major impact on a family. They have to read every label. They have to worry about a play date — maybe the child is going to be fed a food that will make them sick. They have to worry about cross contamination when they go out to a restaurant — maybe before their food was cooked, there was a food to which they are allergic on the grill. Many of these families seldom go out to eat, and do a lot of baking and cooking in the home because that’s the best way to prevent exposure to something that will bring on allergy symptoms.”

The case against peanuts Clearly, preventing food allergies is an important goal. This is especially critical for children at high risk for food allergy, ones the AAP defines as “children who have two parents with food allergy, or children who have a parent and a sibling with food allergy.” For these families, the effort to prevent food allergies starts even before the baby is born. However, it may be a relief to know that even in these high-risk children, restricting the mother’s diet during pregnancy has not been shown to be helpful, with the notable exception of peanuts. Studies show that there is no benefit from prenatal milk and egg avoidance, and avoiding such important foods can decrease mother and infant weight gains. Says Dr. Twarog: “Mom needs to be healthy, too, and cutting out these foods from her diet can decrease her nutritional status and adversely impact the baby.” Peanuts, however, are not an essential food and avoidance will not lead to nutritional deficiencies. “Thus, at least in high-risk families, expectant mothers are urged to avoid peanuts,” the new handbook states. The AAP makes no recommendation in the case of families at lower risk for food allergy. Dr. Judith Goldstein, clinical assistant professor of pediatrics at Mt. Sinai Hospital, states: “Unless there is a strong family history of allergy, restricting the mother’s diet is often not discussed because it is limiting to her own lifestyle.” The revised handbook notes, however, that “once the baby is born, all nursing mothers should begin avoiding peanuts and tree nuts” (and most other kinds of nuts, including almonds, pecans, Brazil nuts, and cashews) until the baby is weaned. For nursing mothers of infants at high risk, several studies have demonstrated that elimination of three common food allergens (peanuts, milk and eggs) from the mother’s diet can delay or prevent some manifestations of food allergy. Proteins from these foods can be excreted in breast milk and can sensitize the baby to them. This is probably why many food-allergic children react to a food the first time they actually eat it. Dr. Goldstein comments: “That’s a difficult diet to observe, but it’s the only course of action conducive to protecting these babies. It’s difficult, but mothers do it because sometimes there is no choice.”

The soy alternative? Well-meaning parents may feed formula-fed infants who are at high risk for food allergy a soy-based formula, thinking they are avoiding sensitizing the infant to milk. Soy, however, is another food that can commonly cause allergies. For the high-risk formula-fed infant, the AAP recommends hypoallergenic, extensively hydrolyzed formulas (such as Nutramigen and Alimentum), unless soy allergy can be ruled out. This is also the type of formula recommended for allergy-prone breastfed infants who occasionally require formula supplementation. Babies at high risk for food allergy should be exclusively fed breast milk or hypoallergenic formula until “six months of age.” Parents of babies at lower risk for food allergy are also advised to follow the guidelines of delaying solids until as close as possible to 6 months of age. When it is time to introduce pureed or baby foods, there are no studies that show that there is an ideal way or order to give these foods. However, try introducing no more than one new food a week, so you can observe for possible allergic reactions, which might include vomiting, diarrhea, rash, or wheezing. Undoubtedly our knowledge about why food allergies occur and how to prevent them will increase over time. Indeed, some day, Megan McAllister may be sitting in her pediatrician’s office with her future children and will marvel at how far we have come in a generation’s time. Meanwhile, the new AAP guidelines serve as an important resource for today’s parents who want to know the latest that medical science has to offer about how best to feed their children. AAP’s recommendations on when to introduce allergy prone foods: cow’s milk 1 year of age eggs 2 years of age peanuts, nuts, fish and shellfish 3 years of age JULIE SILVER, M.D., is an assistant professor at Harvard Medical School and the author of several books including the soon-to-be released, ‘Chronic Pain and the Family’ (Harvard University Press). LINDA COZZENS, M.D., is a pediatrician in private practice, who frequently writes about issues that pertain to improving the health of children. NYC Pediatricians Weigh in on Infant Feeding New York City pediatrician Peter Tesler, M.D., M.P.H., chief of ambulatory pediatrics at St. Luke's-Roosevelt Hospital, says, “Obesity is a significant and dramatic problem in this country. The data suggest that if a child is obese by the age of 6, 50 percent will have obesity as a lifetime problem, so there needs to be much more of an emphasis on instilling a good diet and getting a handle on eating issues early on.” In children, the issue is more about excessive weight gain than poor weight gain. ”It’s the fact that the child’s going to McDonald’s every day, having pizza every afternoon, and having Crispy Kremes for breakfast,” Dr. Tesler says. “But,” he adds, ”if we can encourage some sensible choices, we can make significant inroads on this population” Steven Schwarz, M.D., professor of pediatrics at SUNY Downstate Medical Center in Brooklyn, and chair of pediatrics at Long Island College Hospital in Brooklyn, urges new moms to pay attention to vitamin D. Dr. Schwarz suggests supplementing breastfed infants with vitamin D because “we are seeing a whole lot of rickets.” Thought to be eradicated once the country started fortifying milk with vitamin D years ago, nutrition experts are beginning to see the disorder rear its head again, especially in urban hospitals. Rickets is a childhood nutritional disorder that leads to softening and weakening of the bones. It is primarily caused by lack of vitamin D, calcium and/or phosphate. The body can make its own vitamin D with the help of the sun, but production is stymied by poor sunlight in the winter, and many people, including kids, limit their sun exposure the remainder of the year to protect against skin cancer. “Breastfeeding continues to be the best source of nutrition for a newborn infant,” Dr. Schwarz notes, adding that, “in certain climates, kids are not exposed to sun and in some cultures, kids are heavily covered and wrapped, so they don’t get sun exposure. This in itself is a warning, and clearly we need to be supplementing these kids right from the beginning, in the first month or two of life.” Most formulas contain Vitamin D. Talk to your pediatrician.

Free Guide For Parents on Feeding Children

When can my baby eat solid foods?

How will I know if he or she is allergic to eggs, peanuts or any other food?

I breastfeed. Is that enough? For how long?

Questions like these plaque and perplex new parents, and it’s not like they don’t have enough on their minds! To the rescue: a free, easy-to-understand booklet aptly called, Building Blocks of Children’s Nutrition: A Guide for Parents. In the new booklet, pediatrician/nutrition expert and author Christine Wood, M.D., answers just about all of parents’ questions on child nutrition, from age 5 months to 2 years. The booklet is based on the new guidelines set forth by the American Academy of Pediatrics (AAP) in the latest edition of its Pediatric Nutrition Handbook. The book starts with a helpful nutrition quiz and moves stealthfully into the basics of infant nutrition, healthy snacking, reading complicated nutrition labels and also offers a chart to help track your child’s progress.

Highlights include:

- The AAP recommends breast milk for infants as the primary source of nutrition during a baby’s first year of life. Around 4 to 6 months of age, solid foods can be introduced to your baby, starting with cereal and followed by vegetables and fruit.

- Introduce just one new type of solid food into your baby’s diet every five days so that you can monitor for allergies.

- Toddlers should drink no more than 4-6 ounces of 100-percent juice per day.

For a free copy of brochure, visit www.JuicyJuice.com/BuildingBlocks, where you can request a free copy or download the guide.


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