Bone mineral status in children with cow milk allergy

The association of milk and multiple food avoidance with growth parameters in infants and children

BACKGROUND

Recent studies reported that strict avoidance of milk products in cow's milk allergy (CMA) affects growth and bone turnover, causing negative calcium balance and changes in bone metabolism.

OBJECTIVE

To investigate biochemical parameters to predict bone turnover and its relations with height and weight measurements and nutritional intake.

METHODS

Height, weight, and body mass index z scores were plotted for age according to the World Health Organization. A 3-consecutive day food record was analyzed for nutritional values of foods. The blood levels of calcium, phosphorus, alkaline phosphatase, vitamin D, and parathyroid hormone (PTH) were determined.

RESULTS

The study included 69 controls, 66 children with isolated CMA, and 59 children with multiple food allergy (FA). The z scores for weight, height, and body mass index were lower in isolated CMA and multiple FA groups than controls (P < .001, P = .004, and P = .002, respectively). The nutritional intakes of protein, fat, carbohydrates, vitamins B2 and B12, niacin, calcium, and phosphorus were significantly lower in isolated CMA and multiple FA than controls. In infants (≤2 years of age), although blood calcium level was in normal range, it was significantly lower in isolated CMA and multiple FA than in controls (P < .001). In children older than 2 years, PTH level was significantly higher in isolated CMA and multiple FA groups than in controls (P = .003).

CONCLUSION

Our study revealed that children with isolated CMA and multiple FA had a high nutrition gap, growth deceleration, and unbalanced bone metabolism, as illustrated by low blood calcium and elevated PTH levels.

Impaired bone mineral density and microarchitecture in female adolescents with IgE-mediated cow's milk allergy

This study compared the bone parameters of adolescents with persistent cow's milk allergy (CMA) with those of healthy adolescents. Adolescents with CMA had compromised bone parameters (lower bone mineral density, impaired trabecular microarchitecture, and lower bone strength). Partial exclusion diet was associated with better bone parameters than total exclusion diet.

BACKGROUND

Persistent immunoglobulin E (IgE)-mediated cow's milk allergy (CMA) may impair bone parameters and increase the risk of fractures. High-resolution peripheral quantitative computed tomography (HR-pQCT) is a novel methodology that not only assesses trabecular and cortical bone compartments and volumetric density measurements, but also evaluates bone microarchitecture and estimates biomechanical properties through finite element analysis (FEA). Both HR-pQCT and bone strength parameters derived from FEA have shown a strong correlation with fracture risk.

PURPOSE

To assess the bone density, microarchitecture, and bone strength of adolescents with persistent IgE-mediated CMA (IgE-CMA).

METHODS

This was an observational, cross-sectional study with female adolescents with persistent IgE-CMA and healthy control participants matched by female sex and sexual maturation. Bone parameters were assessed by areal bone mineral density (aBMD) through dual-energy X-ray absorptiometry (DXA), bone microarchitecture by HR-pQCT at the radius and tibia, and laboratory markers related to bone metabolism.

RESULTS

The median age of adolescents with persistent IgE-CMA (n = 26) was 13.0 years (interquartile range (IQR) 11.4-14.7) and of healthy control participants (n = 28) was 13.6 years (IQR 11.9-14.9). Adolescents with IgE-CMA ingested 27.4% less calcium (p = 0.012) and 28.8% less phosphorus (p = 0.009) than controls. Adolescents with IgE-CMA had lower bone mineral content (BMC) (38.83 g vs. 44.50 g) and aBMD (0.796 g/cm2 vs. 0.872 g/cm2) at lumbar spine, and lower BMC (1.11 kg vs. 1.27 kg) and aBMD (0.823 g/cm2 vs. 0.877 g/cm2) at total body less head (TBLH) (p < 0.05). However, Z-scores BMC and Z-scores aBMD at lumbar spine and TBLH, when adjusted for Z-score height/age, were not significantly different between the groups. Moreover, CMA adolescents had lower bone strength at the distal tibia (S 169 kN/mm vs. 194 kN/mm; F Load 8030 N vs. 9223 N) (p < 0.05). Pairing of groups by the presence of menarche showed compromised parameters at the tibia-lower total volumetric BMD (Tt.vBMD) (293.9 mg HA/cm3 vs. 325.9 mg HA/cm3) and trabecular vBMD (Tb.vBMD) (170.8 mg HA/cm3 vs. 192.2 mg HA/cm3), along with lower cortical thickness (Ct.th) (1.02 mm vs. 1.16 mm) and bone strength (S 174 kN vs. 210 kN; F Load 8301 N vs. 9950 N)-and at the radius (S 61 kN/mm vs. 71 kN/mm; F Load 2920 N vs. 3398 N) (p < 0.05) among adolescents with IgE-CMA. Adolescents with IgE-CMA on a total exclusion diet (n = 12) showed greater impairment of bone features than those on a partial exclusion diet (n = 14), with lower lumbar spine Z-score BMC (- 0.65 vs. 0.18; p = 0.013), lumbar spine trabecular bone score (TBS) (1.268 vs. 1.383; p = 0.005), Z-score TBS (0.03 vs. 1.14; p = 0.020), TBLH Z-score BMC (- 1.17 vs. - 0.35; p = 0.012), TBLH Z-score aBMD (- 1.13 vs. - 0.33; p = 0.027), Tt.vBMD at the tibia (259.0 mg HA/cm3 vs. 298.7 mg HA/cm3; p = 0.021), Ct.th at the tibia (0.77 mm vs. 1.04 mm; p = 0.015) and Ct.th at the radius (0.16 mm vs. 0.56 mm; p = 0.033).

CONCLUSION

Adolescents with persistent IgE-CMA had lower aBMD and compromised microarchitecture (impaired trabecular microarchitecture and lower bone strength). Adolescents on a partial exclusion diet had better bone parameters than those on a total exclusion diet.

Dietary management of IgE and non-IgE-mediated food allergies in pediatric patients

Food allergies (FA) consist of both IgE and non-IgE-mediated entities, with varying phenotypes and overlapping and different considerations for each specific disease presentation. In general, all FAs place children at increased risk for inadequate nutritional intake and negative impacts on their nutritional status, as well as negative impacts on the quality of life for the entire family. To minimize these untoward effects, a multidisciplinary approach should be taken, including consultation and management with a dietitian trained in the varying presentations of FA. Families should be instructed on label reading as a first line of nutritional management. During a nutrition consultation, the age of the child, growth, and nutritional status should be considered. Food refusal should be assessed and addressed. Families should be educated on avoidance and appropriate substitutions. In the case of cow's milk allergy, a suitable specialized formula should be suggested if the infant is not breastfed or if breast milk supply is not sufficient. Other mammalian milk should be avoided and careful consideration should be given before plant-based milk is used in young children. Specific food allergies may differ in terms of advice provided on the level of avoidance required, whether precautionary advisory labels should be avoided, and if a maternal avoidance of the allergen during breastfeeding should be advised. The role of immunonutrition on overall health should be discussed.

Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic

BACKGROUND

Food allergies affect growth in children by decreasing the availability of nutrients through decreased dietary intake, increased dietary needs, food-medication interactions, and psychosocial burden. Guidelines on food allergy management frequently recommend nutrition counseling and growth monitoring of children with food allergies.

OBJECTIVE

To provide clear guidance for clinicians to identify children with food allergies who are at nutritional risk and ensure prompt intervention.

METHODS

We provide a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to identify those with food allergy at greatest nutritional risk, determine the impact of nutritional interventions on growth, and develop guidance for risk reduction in children with food allergies.

RESULTS

Children with food allergies are at increased risk of nutritional deficiencies and poor growth. Nutritional assessment and intervention can improve outcomes. Identifying poor growth is an important step in the nutrition assessment. Therefore, growth should be assessed at each allergy evaluation. Interventions to ensure adequate dietary intake for growth include appropriately prescribed elimination diets, breast-feeding support and assessment, supplemental formula, vitamin and/or mineral supplementation, appropriate milk substitutes, and timely introduction of nutrient-dense complementary foods. Access to foods of appropriate nutritional value is an ongoing concern.

CONCLUSION

Nutrition intervention or referral to registered dietitian nutritionists with additional training and/or experience in food allergy may result in improved growth and nutrition outcomes.

Relationship between growth and food avoidance with food allergy at age 3 years: The Japan Environment and Children's Study (JECS)

Background

Basic management for food allergy (FA) is eliminating causative food from the diet, which can impact normal growth. This study examined the association between food avoidance and growth failure among children with FA aged 0-3 years using the Japan Environment and Children's Study (JECS) data.

Methods

Data on height, weight, and FA history registered were collected using self-administered questionnaires at age 1, 1.5, 2, and 3 years. A general linear model was used to examine whether dietary restriction affected body size. Height, weight, and body mass index (BMI) were adjusted for age in months using standard deviation (SD) scores for each age group by month of measurement. Presence of FA or dietary restriction was used as a binary variable.

Results

Of the 38 477 participants included in this analysis, 4070 with FAs had significantly lower SD scores for height and weight at age 3 years. With milk avoidance, significantly lower SD scores for height (male: β = -0.097 [95%CI: 0.175, -0.019], female: β = -0.103 [95%CI: 0.204, -0.002]), a significantly lower SD score for weight (male: β = -0.115[95%CI: 0.187, -0.043], female β = -0.114[95%CI: 0.203, -0.026]) were observed. Soy avoidance in males marked a lower SD score for height (β = -0.307 [95%CI: 0.474, -0.140]). Continued food avoidance until age 3 resulted in significantly lower SD score for height and weight regardless of gender.

Conclusion

Growth impairment was observed with food avoidance at age 3 years. Growth impairment were more obvious in males than in females. With regards food items, the impact of milk and soy was more significant.

Nutritional Strategies for the Prevention and Management of Cow's Milk Allergy in the Pediatric Age

Cow's milk allergy (CMA) is one of the most common pediatric food allergies. The prevalence and severity of CMA have increased dramatically in the last decades, under the pressure of environmental factors in genetically predisposed individuals. Among the environmental influences, nutritional factors play a crucial role. Diet is the most modifiable factor, representing a potential target for the prevention and treatment of CMA. In this review, we report the most scientific-based nutritional strategies for preventing and managing pediatric CMA. In addition, we propose the most complete supplement of compounds able to prevent nutrient deficiencies in CMA pediatric patients and to positively influence the disease course.

Pilot Study of the Applicability, Usability, and Accuracy of the Nutricate© Online Application, a New Dietary Intake Assessment Tool for Managing Infant Cow's Milk Allergy

BACKGROUND/OBJECTIVES

The mainstay treatment of cow's milk allergy (CMA) is to remove cow's milk proteins from children's dietary intake. In this context, dietary intake of children with CMA should be particularly checked and monitored. The objective of this study was to assess the applicability, usability, and accuracy of a new dietary intake (DI) assessment online tool (Nutricate© online application) for managing CMA in children.

SUBJECTS/METHODS

This study used a pre-existing database of DI from the Nutricate© online application. DIs from 30 CMA children were used to compare micro/macronutrients (energy, protein, calcium, and iron intakes) calculated by Nutricate© and NutriLog© as the reference method. Comparisons were performed using the Pearson correlation analysis and the Bland-Altman plot. The Nutricate© tool usability was assessed via a System Usability Scale questionnaire (SUSq).

RESULTS

Correlation coefficient between the levels of micro/macronutrients obtained by Nutrilog© and Nutricate© software were highly significant (p = 0.0001) and were well-correlated (R coefficient > 0.6), indicating a very good concordance between the two methods. This observation was reinforced by the Bland-Altman plot, indicating the absence of proportional or fixed bias for energy, protein, calcium, and iron intakes. The mean SUSq score obtained was 81 ± 14, which is considered to be an excellent score.

CONCLUSIONS

Nutricate© online application is a reliable method to assess micro/macronutrient (energy, protein, calcium, and iron intakes) intake in CMA children. Applicability and usability of this new dietary intake assessment online tool is excellent.

Nutrient intake in school-aged children with food allergies: a case-control study

Most studies assessed nutrient intake of young children with food allergy (FA) compared to healthy children. We aimed to compare macro- and micronutrient intake of school-aged children with FA to non-allergic children. This case-control study included 93 Italian children (52 with FA and 41 controls, median age 7.5 and 8.3 years, respectively). Macro- and micronutrient intake was assessed by a three-day food dietary record. Anthropometric measurements were also collected. The median height z-score was significantly lower in the FA group, despite a similar daily energy and protein intake. Calcium, iron and vitamin D intake was suboptimal in both groups, while protein intake was higher than recommended in both groups. Unexpectedly, children with FA consume more protein than controls, while having lower micronutrient intake, especially calcium. Our data suggest the importance of nutritional counseling for children with FA to ensure a balanced nutrient intake while on elimination diet.

Recent perspective on cow's milk allergy and dairy nutrition

Cow's milk is a highly nutritious biological fluid that provides nourishment and immunity to infants when breastfeeding declines. However, some infants, children, and adults are allergic to cow's milk because milk contains potential allergens in the form of proteins. Casein and whey proteins and their coagulated sub-fractions in the milk such as αS₁-casein, αS₂-casein, β-casein, κ-casein and α-lactalbumin, β-lactoglobulin, bovine serum albumin, immunoglobulins, lactoferrin, respectively are the major etiological determinant of cow's milk allergy (CMA). Moreover, milk processing techniques such as homogenization and pasteurization alter the milk fat and whey protein's molecular structure and serve them as allergens to the immune system of allergic individuals. Strict exclusion of nutrient-rich milk and other dairy products from diet puts children with CMA at higher nutritional risk. Thus, regular nutritional monitoring, the inclusion of protein and mineral-rich supplements as a substitute for cow's milk, management of animal genetics (sheep, goats, buffaloes, camel, mare, donkey, yak), and milk processing to produce non-allergenic milk by inactivating allergic proteins for designer nutrition is essentially required. This review paper details the prevalence, molecular profiling of milk allergens (proteins), body immune response against CMA, consequences of milk processing, treatment, and novel role of galectins as potentially allergy suppressors.

Managing Younger Siblings of Food Allergic Children

Current guidelines state that there is insufficient evidence to recommend testing siblings of food allergic children before introduction of potential allergic foods, but the topic continues to remain controversial. Although the proportion of siblings who are sensitized to a food without clinical reactivity is high in comparison to those with a true food allergy, there is still a known increased risk amongst siblings of children with food allergies that has led to much apprehension about management. The appropriateness of testing and further steps for management of sensitization in the absence of history of clinical reactivity should be discussed with parents.

Reduced Final Height and Inadequate Nutritional Intake in Cow's Milk-Allergic Young Adults

BACKGROUND

Growth impairment was previously described in milk-allergic children but was not examined in adults on reaching final height.

OBJECTIVES

To investigate the dietary intake and final stature of young adults with IgE-mediated cow's milk allergy (IgE-CMA) as compared with nonallergic controls.

METHODS

Eighty-seven patients with IgE-CMA, median age 19.5 years (interquartile range [IQR], 17.3-22.7), and 36 control participants without food allergies, median age 22.7 years (IQR, 18.9-26.1), were studied. Anthropometric and nutritional data were collected. Age and gender z-scores were determined according to the Centers for Disease Control and Prevention growth charts. Nutrient intake assessment was based on dietary records. Individuals with conditions or treatments affecting bone metabolism or growth, other than asthma, were excluded.

RESULTS

Mean values of height z-scores were significantly reduced in CMA subjects compared with controls (-0.64 ± 0.9 vs -0.04 ± 0.7, P = .001). In contrast, no differences were found between the 2 groups in weight and body mass index z-scores. Patients with CMA had significantly lower intake of protein, and several essential vitamins (A, B12, and riboflavin) and minerals (calcium, potassium, phosphorus, magnesium, and zinc) compared with controls (P < .05), but the intakes of calories, carbohydrate, and fat were not significantly different between the 2 groups. Differences between actual and expected (based on midparental height) height z-scores were comparable in CMA subjects with or without asthma and between those with and without additional food allergies.

CONCLUSIONS

Young adults who have CMA from infancy are at risk of not reaching their growth potential. Growth and nutritional monitoring and appropriate dietary intervention are of particular importance in these at-risk individuals.

Nutritional disorders resulting from food allergy in children

The elimination of food allergens that contribute essential nutrients in paediatrics may lead to the development of nutritional disorders. The most common nutritional disorders include poor growth, micronutrient deficiencies and feeding difficulties. Of the aforementioned, growth faltering has been well studied and is seen as a common presenting factor in paediatric food allergy. However, the use of different criteria and cut-off values makes it difficult to establish the overall effect. The impact of number and type of foods eliminated and comorbidities has yielded varying results, although there seems to be a trend towards worsening growth with atopic dermatitis and the avoidance of cow's milk. Low micronutrient intake is common in paediatric food allergy; however, a low intake does not necessarily translate into a deficiency as measured by biomarkers. Vitamin D and calcium have been well studied, and a long-lasting impact on bone mineral density has been found. However, other micronutrient deficiencies have also been found and should also be considered. Feeding difficulties is a common complaint in clinical practice, but limited data have been published in food allergy. Poor growth and reflux/vomiting have been shown to be associated with feeding difficulties, in particular in non-IgE-mediated food allergies. There seems to be a long-lasting effect on feeding, in particular in cow's milk allergy, which needs to be taken into account with dietary input. The interplay between growth, feeding difficulties and micronutrient deficiencies has been implied in some studies, but cause and effect is not well established and requires further research.

Bone health assessment of food allergic children on restrictive diets: a practical guide

BACKGROUND

Food allergy in childhood is on the rise globally and is managed with avoidance diets; recent case reports of food allergic children with nutritional rickets in the literature highlight the importance of close monitoring of bone health in this population.

METHODS

There is no consensus as yet with regard to bone health evaluation in food allergic children; therefore, extensive literature search was performed and the existing evidence is presented, along with a relevant algorithm.

RESULTS

Children allergic to cow's milk protein or presenting with allergy in more than three food items, as well as patients with severe allergic phenotypes or comorbidities known to affect the skeleton, seem to be at risk of metabolic bone disorders. As a practical guide, suspicious cases can be investigated with basic bone profile, whereas more severe cases (persistent bone pain and fractures) may undergo advanced bone health assessment, with bone mineral density (BMD) and metabolic bone markers' evaluation. Of note, these diagnostic steps call for further studies in the field of food allergy, as they are not performed as a routine. Evidence is accumulating with regard to vitamin D deficiency, osteopenia and imbalanced bone metabolism in those food allergic children who show poor dietary compliance or have inadequate medical supervision.

CONCLUSIONS

Ensuring optimal bone accrual in a food allergic child is an important task for the clinician and requires close monitoring of the restrictive diet and prompt therapeutic intervention, in an effort to avoid rickets or osteopenia.

Nutritional adequacy of a cows' milk exclusion diet in infancy

BACKGROUND

Infants with suspected cows' milk allergy are required to follow a strict milk exclusion diet which may lead to nutritional deficiencies, especially if not supervised by a healthcare professional. The aim of this study was to assess the nutritional adequacy of a cows' milk exclusion diet in a group of UK infants over a period of 6 months.

METHODS

Participants in this study are a subgroup of the Prevalence of Infant Food Allergy study, a prospective food allergy birth cohort study from the South of England. Each infant consuming a milk free diet, following advice from a specialist allergy dietitian, was matched to two control infants who were consuming an unrestricted diet, forming a nested matched case-control study. Detailed food diaries completed prospectively for 1 week per month over a 5 month period, were coded and analysed according to a standard protocol.

RESULTS

The diets of 39 infants (13 milk-free and 26 controls) were assessed. Mean age at diet commencement was 14 weeks. Two of the eleven infants started on an extensively hydrolysed formula did not tolerate it and required an amino acid formula for symptom resolution. All infants had mean intakes in excess of the estimated average requirement for energy and the recommended nutrient intake (RNI) for protein, calcium, iron, selenium, zinc, vitamins A, C and E. Vitamin D intake was in excess of the RNI at all time-points, except at 44 weeks of age. Across the study period, selenium intake was higher for infants consuming a milk free diet whilst vitamin C intake was higher for infants consuming an unrestricted diet. Differences were found between the two groups for protein, calcium, iron and vitamin E intakes at differing time points.

CONCLUSION

This study demonstrated that although infants consuming a milk-free diet have a nutritional intake that is significantly different to matched controls who are eating an unrestricted diet, this difference is not constant and it is not seen for all nutrients. Further research in infants without dietetic input is needed to explore the nutritional implications of unsupervised cows' milk exclusion diets.

Cow's Milk Allergy and Bone Mineral Density in Prepubertal Children

BACKGROUND AND OBJECTIVES

Recent data suggest that cow's milk allergy (CMA) has become more persistent, prolonging treatment via strict elimination of cow's milk products into a period of skeletal growth. The objectives of this study were to compare bone mineral density (BMD), vitamin D status, and dietary intakes of calcium and vitamin D between prepubertal children with persistent CMA and those with non-cow's milk food allergies (NCMA) as control subjects and to assess the use of and compliance to calcium and vitamin D supplementation among children with persistent CMA.

METHODS

Fifty-two children with persistent CMA and 29 with NCMA were recruited. BMD was measured by using dual energy radiograph absorptiometry, and vitamin D status was assessed by using plasma 25-hydroxyvitamin D concentrations. Calcium and vitamin D intakes, as well as compliance to calcium and vitamin D supplementation, were recorded.

RESULTS

Lumbar spine BMD z scores were significantly lower in children with CMA. Low bone mass was detected in 6% of the CMA group compared with none in the NCMA group. Children with CMA displayed significantly lower calcium intakes than control subjects. Vitamin D status was not reduced in children with CMA compared with control subjects. Fewer than one-half of children with CMA reported the use of calcium and vitamin D supplements. However, adherence was high among supplement users, with a mean compliance rate of 5.5 days per week.

CONCLUSIONS

These prepubertal children with persistent CMA had lower lumbar spine BMD z scores than children with NCMA, which likely resulted from lower calcium intake.

Clinical management of food allergy

Food allergies are commonly seen by the practitioner, and managing these patients is often challenging. Recent epidemiologic studies report that as many as 1 in 13 children in the United States may have a food allergy, which makes this an important disease process to appropriately diagnose and manage for primary care physicians and specialists alike. Having a understanding of the basic immunologic processes that underlie varying presentations of food-induced allergic diseases will guide the clinician in the initial workup. This review will cover the basic approach to understanding the immune response of an individual with food allergy after ingestion and will guide the clinician in applying appropriate testing modalities when needed by conducting food challenges if indicated and by educating the patient and his or her guardian to minimize the risk of accidental ingestion.

Biochemical markers of bone metabolism in children with cow's milk allergy

INTRODUCTION

Patients with cow's milk allergy (CMA) and following a cow milk protein-free diet for a long time are potentially at risk of developing bone abnormalities. To assess the balance between bone formation and resorption processes, we determined serum concentrations of osteocalcin (OC), bone alkaline phosphatase (BALP), C-terminal telopeptide of type I collagen (CTX), fetuin-A, osteoprotegerin (OPG) and receptor activator of nuclear factor κB ligand (RANKL) in children with CMA.

MATERIAL AND METHODS

The study included 50 prepubertal children with diagnosed cow's milk allergy, who were under systematic medical and nutritional care at the Institute of Mother and Child and 40 healthy counterparts as a control group. The concentrations of bone metabolism markers were determined by immunoenzymatic assays.

RESULTS

The diets of all investigated children were correct in terms of phosphorus and magnesium contents but deficient in terms of calcium and vitamin D. Serum OC and CTX as well as fetuin-A concentrations were similar in both studied groups. The BALP activity was significantly (p < 0.05) higher in children with cow's milk allergy than in the controls. Serum OPG concentration was comparable in both groups, but the RANKL level was higher (p < 0.05) in CMA children than in healthy ones. Hence, the ratio of OPG/RANKL was lower in children with CMA.

CONCLUSIONS

Our study demonstrates slight disturbances in the profile of bone metabolism markers in growing children with CMA. The increase in RANKL level and decrease in OPG/RANKL ratio may contribute to intensification of bone resorption in these patients.

Nutritional aspects of bone health

Bone mass, geometry and microstructure, and bony tissue material level properties determine bone strength, hence the resistance to fracture. At a given age, all these variables are the consequence of the amount accumulated and of the structure developed during growth, up to the so-called peak bone mass, and of the bone loss and microstructure degradation occurring later in life. Genetic factors primarily contribute to the variance of the determinants of bone strength. Nutritional intakes are environmental factors that influence both processes, either directly by modifying modelling and remodelling, or indirectly through changes in calcitropic hormone secretion and action. Some effects of nutrition on the offspring bone could take place during foetal life. There are interplays between genetic factors, nutritional intakes and physical exercise. Among the nutrients, sufficient dietary intakes of calcium and protein are necessary for bone health in childhood and adolescence as well as later in life.

Dairy food at the first occasion of eating is important for total dairy food intake for Australian children

The cross-sectional 2007 Australian National Children’s Nutrition and Physical Activity Survey collected detailed dietary information from a representative sample of more than 4400 children by 24-h dietary recall. Dairy food intake by Australian children is substantially lower than recommendations, and decreases as a percentage of energy intake as children grow older. Children aged 2 to 16 years are, on average, 2.3 times more likely to have a dairy food at the first daily occasion of eating, than at the second occasion. For children who consumed any dairy food at the first occasion of eating, the total daily intake of dairy foods was 129% (95% CI 120%–138%) greater than for children who did not consume a dairy food at the first occasion of eating. Their dairy food intake for the rest of the day following the first occasion of eating was also greater by 29% (95% CI 21%–37%). Younger age group, male sex, location of eating being at home or in a residence and starting the first occasion of eating from 6 a.m. to 9 a.m. are all jointly associated with having a dairy food at the first occasion of eating. A simple strategy to increase Australian children’s intake from the dairy and alternatives food group may be to make sure that the first occasion of eating each day includes a dairy food or a nutritional equivalent.

Growth and nutritional concerns in children with food allergy

PURPOSE OF REVIEW

To describe the potential effect that avoidance diets for food allergy may have on nutrition and growth in children.

RECENT FINDINGS

We report here the findings from the previous studies suggesting impairment of growth and nutritional deficiencies because of elimination diets for food allergy. Feeding difficulties have also been reported, particularly in children with eosinophilic esophagitis that may further impact the nutrient intake.

SUMMARY

Food allergies are becoming more prevalent and better recognized. Treatment options typically include strict dietary elimination of major food allergens such as milk, eggs, wheat, soy, peanut, tree nuts, fish and shellfish. Monitoring growth and guiding food allergic patients in choosing appropriate alternatives to supply necessary nutrients becomes crucial to avoid deficiencies and retardation in growth.

Ultrasound velocity through the tibia is not affected by prolonged inhaled steroid therapy in children

AIM

To evaluate in a prospective, cross-sectional cohort study the impact of inhaled corticosteroids (ICS) on bone speed of sound (SOS) in asthmatic children.

METHODS

Children with mild-to-moderate asthma from a pulmonary clinic were assessed over a 2-month period. We recorded clinical and demographic data related to asthma severity, its treatment, participation in sports and dairy intake. Tibial SOS was measured using the Sunlight Omnisense 7000S quantitative ultrasound bone sonometer.

RESULTS

Eighty-five mild-to-moderate asthmatic children were studied. Age range was 1.4-17 years (71.7% boys). Average disease duration was approximately 5 years, and the average cumulative duration of ICS therapy was approximately 1.5 years. Average SOS Z-score was slightly negative and varied between -3.5 and +1.9 SD. In univariate analysis, SOS Z-score was negatively correlated with asthma duration (R(2) = 5.7%, p = 0.028) and ICS duration (R(2) = 4.9%, p = 0.042). In backward stepwise multiple regression, where SOS Z-score was the dependent variable, the only variables that remained significant in the final analysis were gender (p = 0.015), asthma duration (p = 0.003) and BMI (p = 0.048) (R(2) for the model 17.52% p = 0.01).

CONCLUSION

Prolonged inhaled steroid therapy appears to have no deleterious effect upon SOS in children with mild-to-moderate persistent asthma.

Dietary treatment of cows' milk protein allergy in childhood: a commentary by the Committee on Nutrition of the French Society of Paediatrics

The diagnosis of cows' milk protein allergy (CMPA) requires first the suspicion of diagnosis based on symptoms described in the medical history, and, second, the elimination of cows' milk proteins (CMP) from the infant's diet. Without such rigorous analysis, the elimination of CMP is unjustified, and sometimes harmful. The elimination diet should be strictly followed, at least until 9–12 months of age. If the child is not breast fed or the mother cannot or no longer wishes to breast feed, the first choice is an extensively hydrolysed formula (eHF) of CMP, the efficacy of which has been demonstrated by scientifically sound studies. If it is not tolerated, an amino acid-based formula is warranted. A rice protein-based eHF can be an alternative to a CMP-based eHF. Soya protein-based infant formulae are also a suitable alternative for infants >6 months, after establishing tolerance to soya protein by clinical challenge. CMPA usually resolves during the first 2–3 years. However, the age of recovery varies depending on the child and the type of CMPA, especially whether it is IgE-mediated or not, with the former being more persistent. Once the child reaches the age of 9–12 months, an oral food challenge is carried out in the hospital ward to assess the development of tolerance and, if possible, to allow for the continued reintroduction of CMP at home. Some children with CMPA will tolerate only a limited daily amount of CMP. The current therapeutic options are designed to accelerate the acquisition of tolerance thereof, which seems to be facilitated by repeated exposure to CMP.

Diet and nutritional status of children with food allergies

The aim of the present study was to assess the food intakes and nutritional status of children with food allergies following an elimination diet. We conducted a cross sectional study including 96 children (mean age 4.7 ± 2.5 years) with food allergies and 95 paired controls (mean age 4.7 ± 2.7 years) without food allergies. Nutritional status was assessed using measurements of weight and height and Z scores for weight-for-age, height-for-age and weight-for-height. Nutrient intakes assessment was based on a 3-day diet record. Children with food allergies had weight-for-age and height-for-age Z scores lower than controls (0.1 versus 0.6 and 0.2 versus 0.8 respectively). Children with 3 or more food allergies were smaller than those with 2 or less food allergies (p = 0.04). A total of 62 children with food allergies and 52 controls completed usable diet records. Energy, protein and calcium intakes were similar in the two groups. Children with food allergies were smaller for their age than controls even when they received similar nutrient intakes. Nutritional evaluation is essential for the follow up of children with food allergies.

The effect of past food avoidance due to allergic symptoms on the growth of children at school age

BACKGROUND

The influence of food avoidance due to allergic symptoms in infancy on the growth of children at school age has not been well evaluated.

METHODS

To determine the growth of schoolchildren who avoided eggs, milk, or wheat due to immediate allergic symptoms in infancy (food avoiders in infancy) (FAI), a questionnaire on the presence of allergic diseases, as well as present height and weight, was administered to the parents of 14,669 schoolchildren. 11,473 subjects had available data. The height and weight standard deviation scores (HtSDS and WtSDS) and body mass index percentile (BMI percentile) of each subject were calculated.

RESULTS

FAI had significantly lower WtSDS than non-FAI (P = 0.01). Among those with avoidance at age 3 years, those who avoided two or more foods and those who avoided milk had significantly lower HtSDS than their counterparts (P = 0.02 and 0.04, respectively). FAI had a significantly lower prevalence of obesity (P = 0.01) and overweight (P = 0.002), while there was no difference in the prevalence of underweight (P = 0.58), resulting in a significantly higher prevalence of appropriate weight (P = 0.01) compared to non-FAI. Significantly lower prevalence of obesity and overweight was observed even among those who terminated the avoidance by age 3 years.

CONCLUSIONS

FAI were less likely to be obese or overweight, resulting in a higher prevalence of appropriate weight at school age. Further investigation should contribute to better management of food allergy and obesity.

Maximizing bone mineral mass gain during growth for the prevention of fractures in the adolescents and the elderly

Bone mass is a key determinant of fracture risk. Maximizing bone mineral mass during childhood and adolescence may contribute to fracture risk reduction during adolescence and possibly in the elderly. Although more than 60% of the variance of peak bone mass (PBM), the amount of bone present in the skeleton at the end of its maturation process, is genetically determined, the remainder is likely influenced by factors amenable to positive intervention, such as adequate dietary intake of dairy products as a natural source of calcium and proteins, vitamin D, and regular weight-bearing physical activity. Low calcium and vitamin D intakes are associated with negative effects on bone, including suboptimal PBM acquisition. As suggested by intervention studies, regular intake of dairy products may have positive and possibly sustained effects on bone mineral mass gain, contributing thereby to fracture risk reduction. Further evidence from intervention studies suggests that weight-bearing physical activities, such as jumping, may contribute to bone mineral mass gain in children. Optimizing PBM acquisition through dietary and physical exercise measures may represent a valuable primary method for the prevention of fractures.

Nutrition: its role in bone health

At a given age, bone mass is determined by the amount of bone accumulated at the end of skeletal growth (the so-called peak bone mass), and by the amount of bone lost subsequently. Nutritional intake is an environmental factor that influences both bone capital accumulation, which is fully achieved by the end of the second decade of life, and bone loss, which occurs during the second half of existence. Nutrients may act directly by modifying bone turnover, or indirectly via changes in calciotropic hormone secretion. The study of the association between nutrition and a bone phenotypic expression may provide inconsistent results, in part because of the low accuracy and reproducibility of the various tools used to assess dietary intakes. Sufficient dietary calcium and protein are necessary for bone health during growth as well as in the elderly.

Multiple Bone Fractures in an 8-Year-Old Child with Cow’s Milk Allergy and Inappropriate Calcium Supplementation

The case of an 8-year-old boy with severe bone mass reduction and 4 fractures as a result of an unsupervised diet established to treat cow's milk allergy is presented. Endocrine, genetic and orthopedic pathologies were excluded. While vitamin D intake had always been appropriate, his calcium intake had been inadequate for many years. This clinical report suggests that both vitamin D and calcium supplementation are necessary when a cow's milk protein-free diet is prescribed, even when a hypo- or non-allergenic formula is provided.

Meeting adequate intake for dietary calcium without dairy foods in adolescents aged 9 to 18 years (National Health and Nutrition Examination Survey 2001-2002)

BACKGROUND

In the United States, >50% of dietary calcium is provided by milk and milk products. Calcium intakes in the United States are inadequate for many children, and a large proportion do not drink milk or consume dairy products. However, no studies have addressed whether dairy-free diets can provide adequate calcium while meeting other nutrient recommendations.

OBJECTIVE

To determine the highest calcium intake for adolescents obtained from dairy-free diets, and to examine the relationship between intakes of calcium-fortified foods, using citrus juice as an example, and maximal calcium intakes.

DESIGN

In the National Health and Nutrition Examination Survey 2001 to 2002, 65 females and 62 males, aged 9 to 18 years, reported no intake of dairy. We used linear programming to generate diets with maximal calcium intake, while meeting Dietary Reference Intakes for a set of nutrients, limiting energy and fat intakes, and not selecting food quantities exceeding amounts usually eaten in the population.

RESULTS

With food use and energy and fat constraints, diets formulated by linear programming provided 1,150 and 1,411 mg/day of calcium for girls and boys, respectively. With the Dietary Reference Intakes constraints, these decreased to 869 and 1,160 mg/day. When we introduced 1.5 servings of fortified juice to the diets, the highest calcium intake increased to 1,302 mg/day for girls and to 1,640 mg/day for boys.

CONCLUSIONS

Adequate intake for calcium cannot be met with dairy-free diets while meeting other nutrient recommendations. To meet the adequate intake for calcium without large changes in dietary patterns, calcium-fortified foods are needed. In addition, greater physical activity and responsible sunlight exposure should be encouraged to promote vitamin D adequacy.

Cow's milk and linear growth in industrialized and developing countries

The strongest evidence that cow's milk stimulates linear growth comes from observational and intervention studies in developing countries that show considerable effects. Additionally, many observational studies from well-nourished populations also show an association between milk intake and growth. These results suggest that milk has a growth-stimulating effect even in situations where the nutrient intake is adequate. This effect is supported by studies that show milk intake stimulates circulating insulin-like growth factor (IGF)-I, which suggests that at least part of the growth-stimulating effects of milk occur through the stimulation of IGFs. Given that the biological purpose of milk is to support the newborn during a period of high growth velocity, such an effect seems plausible. Adding cow's milk to the diet of stunted children is likely to improve linear growth and thereby reduce morbidity. In well-nourished children, the long-term consequences of an increased consumption of cow's milk, which may lead to higher levels of IGF-I in circulation or an increase in the velocity of linear growth, are likely to be both positive and negative. Based on emerging data that suggest both growth and diet during early life program the IGF axis, the association between milk intake and later health is likely to be complex.