Download The importance of calcium in a cows` milk free weaning diet

Examples of non-dairy calcium fortified products:
The importance of calcium
in a cows' milk free weaning diet
• Fortified cereals such as fortified porridge
•Bread*
• Some juices and water have added calcium
• Calcium fortified dairy alternatives such as:
– Shop bought milk alternatives e.g. oat, coconut, soya and nut milks, which are
fortified with calcium at the same level of cows’ milk**
– Some of the milk free desserts, yoghurts, custard and cream alternatives
available are also fortified with calcium
• Some nuts, seeds and dried fruits e.g. almonds, sesame seeds and dried fruits
such as dried apricots and figs
Additional information on non-dairy calcium sources.
Calcium content
per 100g/ml
Portion size
Calcium content
per portion
Fortified oat porridge
1340mg
15g (1 tablespoon)
201mg
Fortified baby porridge
240mg
25g
60mg
Calcium fortified cereals
460mg
15g (1 tablespoon)
69mg
White bread
177mg
36g (1 slice)
64mg
Brown bread*
106mg
36g (1 slice)
24mg
Calcium fortified bread
472mg
38g (1 slice)
179mg
Calcium enriched milk alternatives
e.g. oat, soya, coconut and nut milks**
120mg
100ml
120mg
Fortified milk free yoghurt/dessert
e.g. soya yoghurt
120mg
50g
60mg
Dried apricots
73mg
25g (3 apricots)
18mg
Almonds
240mg
15g
36mg
Broccoli
44mg
30g (1 spear)
13mg
Calcium enriched orange juice
122mg
100ml
122mg
*
For more information on the effective management
of cows' milk allergy visit:
eln.nutricia.co.uk
References: 1. H. E. Theobold. Dietary calcium and health. Briefing paper. British Nutrition Foundation, London, UK 2005. 2. Committee to Review Dietary References intakes for Vitamin D and Calcium, Food and
Nutrition Board, Institute of Medicine. Dietary References Intakes for calcium and vitamin D. Washington, DC: National Academy Press, 2010. 3. Lanham-New S, Thompson RL, More J, Brooke-Wavell K, Hunking P,
Medici E. Importance of vitamin D, calcium and exercise to bone health with specific reference to children and adolescents. Nutrition Bulletin 2007; 32(4):364-377. 4. Department of Health Committee on Medical
Aspects of Food Policy (COMA) set dietary reference values (DRV) for calcium in 1991 (Department of Health 1991). 5. Heaney RP, Abrams S, Dawson-Hughes B et al. Peak bone mass. Osteoporosis International
2000; 11(12): 985-1009. 6. Caroli A et al. Invited review: Dairy intake and bone health: A viewpoint from the state of the art. J Dairy Sci 2011;94(11):5249-62. 7. Kwak HS et al. Revisiting lactose as an enhancer of
calcium absorption. Int Dairy J 2012;22(2):147-51. 8. Rafferty K et al. Calcium fortificants: Overview and strategies for improving calcium nutriture of the U.S. population. J Food Sci 2007;72(9):R152-8
*It is a mandatory requirement that white and brown wheat
flours contain specified amounts of calcium, which is achieved
through fortification.1 Some breads have additional even
higher levels of calcium added.
**These drinks are suitable to use in cooking or used in cereals
from 6 months of age.
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding.
Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth to 6 months of age. Aptamil Pepti 2 is suitable for babies over 6 months as part of a
mixed diet, and as a principle source of nourishment with other foods.
Healthcare professional helpline
0800 996 1234 eln.nutricia.co.uk
SPD675 / November 2016
Food
Rachel de Boer
Paediatric Allergy Dietitian
Dietary assessment and recommendations
Rachel has worked as a Dietitian for over 10 years. She specialises in the diagnosis and management of
children with complex dietary needs due to multiple food allergies and has worked in the paediatric allergy
service of a leading London teaching hospital for over 7 years. She is a committee member of the Food
Allergy and Intolerance Specialist group (FAISG) of the British Dietetic Association and is on the Executive
committee of the Allergy Academy. She has presented at various National and International conferences.
As a Paediatric Dietitian working with cows’ milk allergic
infants and those with multiple food allergies, ensuring
adequate calcium intake is an important consideration
and one of the most common questions asked by parents
with a cows’ milk allergic infant. This information leaflet
explains why calcium is important, particularly during
early childhood and illustrates how calcium requirements
can be achieved in infants with cows’ milk allergy (CMA).
Why is calcium important?
Calcium is an essential nutrient and the most abundant
mineral in the body.1 It has several important functions;
its major role is to help to build strong bones and teeth,
but it is also needed to regulate vascular contraction and
vasodilation, nerve transmission and muscular function.2 Less
than 1% of the body’s calcium is used for these metabolic
functions as the majority (~99%) of calcium present in the
body is found in bone, with a smaller amount found in teeth.1
Calcium and bone
Bones increase in size and mass during periods of growth in
childhood and adolescence, reaching peak bone mass (PBM)
between 18-30 years of age1. Calcium is essential for bone
growth as it is required for the mineralisation of bone.2
This is why an adequate intake of calcium is one of the
factors which is important for attaining PBM and hence
reducing the risk of osteoporosis.1
Calcium requirements in infancy
Periods of particularly fast growth result in accelerated bone
mass, which is why calcium requirements are at their highest
in infancy and adolescence.3 The Department of Health’s
Committee on Medical Aspects of Food Policy (COMA) set
dietary reference values (DRV) for calcium in 1991.4 The
UK reference nutrient intake (RNI) for calcium in infancy is
525mg. The RNI is defined as the amount of a nutrient that
is sufficient, or more than sufficient to meet the nutritional
requirements of practically all (97.5%) healthy people in a
population.4 Therefore, the RNI exceeds the needs of most
individuals. The LRNI (lower reference nutrient intake) for
calcium in infancy is 240mg.1
Why is calcium intake a consideration for
infants with cows’ milk allergy?
The major sources of calcium for infants are breastmilk
or formula milk, however these do not generally provide
100% of the RNI. Other foods within the weaning diet also
contribute to total calcium intake; for the majority of infants,
it is predominately dairy foods such as yoghurt and cheese
and fortified products such as cereals and bread that make
up the calcium shortfall.1 However when an infant has cows’
milk allergy and requires a milk free diet, they need to avoid
dairy products, hence limiting the calcium sources within
their weaning diet. This is usually not a problem with the
right dietary advice on dairy-free weaning, as there are many
other non-dairy foods which contain calcium or are fortified
with calcium which can be introduced – see examples on
opposite page.
A diet history and nutritional assessment is recommended to
assess the calcium sources within a cows' milk allergic infant’s
diet. If these are not adequate some simple suggestions can
often be made to help increase the calcium content of the
infant’s diet from non-dairy sources.
The example diet diaries below give ideas of how the diet can
be adapted to ensure adequate calcium intake in infants with
CMA.5,6
Calcium per portion
On waking
126mg
2
200ml Aptamil Pepti
Breakfast
it
1 x 15mg Wheat biscu
added calcium)
ith
(w
100ml Oat milk
erries/peach slices
30g Finger food: blueb
Mid morning
ots
chopped dried apric
35g Finger food: 4 x
DIET DIARIES
RNI for calcium
(0-12 months) =
Calcium pe
r portion
126mg
134mg
72mg
)
Mid mornin
g
Finger food
: 20g Banan
a/
Lunch
role
120g Chicken Casse
ccoli (1 spear)
30g Finger food: Bro
ith added calcium)
60g Soya yoghurt (w
13mg
72mg
63mg
Dinner
15g Hummous
rmal white bread)
36g Toast soldiers (no
+ sugar snap peas
30g Red pepper slices
slices
40g Mango and pear
On waking
200ml Apta
mil Pepti 2
Breakfast
10g Fortifi
ed porridg
e
60ml Oat m
ilk (with ad
ded calcium
When assessing calcium intake it is important to consider
the bioavailability of this calcium.5 This refers to the fraction
of dietary calcium that is potentially absorbable and the
incorporation of the absorbed calcium into bone.5,6
Various dietary factors can affect calcium bioavailability.
For example some food components act synergistically to
promote calcium absorption.5,6 They include:
30mg
Mid afternoon
2
100ml Aptamil Pepti
525mg
The foods in bold are those which have been added in
to increase the infant’s calcium intake.
Bioavailability of calcium
Before bed
2
200ml Aptamil Pepti
e
Total calcium intak
620mg
Typical formula fed
7 month old infant
• Lactose: Several studies have shown that lactose
appears to have a positive effect on calcium utilisation.7
(daily hypoallergenic formula
milk intake = 600ml)
Other factors inhibit calcium absorption such as oxalates
and phytates. These are found in many plant foods such
as spinach and watercress in considerable amounts. They
bind to calcium and form insoluble salt complexes, thus
decreasing calcium absorption.3
For example, cooked spinach contains 115mg calcium
per 125ml serving, but only an estimated 5% (6mg) of it
is actually absorbed. This is very little compared to the
32% (101mg) of milk’s calcium absorbed.6 However, the
bioavailability of calcium from some other plant foods is
good, e.g. broccoli.1
Lunch
60g Vegeta
ble medley
with 30g flak
ed tinned sa
lmon
Finger food
: 20g Cucum
b
e
r sticks
60g Rice p
udding
(with 50ml
calcium fo
rtified coco
nut milk)
Mid aftern
oon
200ml Apta
mil Pepti 2
Dinner
20g Rice
20g Lentil st
ew
20g Finger
food: Avoca
do slices
20g Mixed
fruit puree
677mg
Notes:
• Portion sizes taken from Caroline Walker Trust Eating Well: First year of life.
Practical Guide. 2011
• Calcium content of foods taken from McCance and Widdowson's Composition of Foods and product information from manufacturers
(correct January 2016 but please note recipes/manufacturing techniques change)
• Foods with calcium content of < 10mg calcium per portion not included within the calcium intake calculation.
It is recommended that all formula fed infants
(under 1 year) drink at least 600ml formula milk
daily, to ensure that they meet their nutritional
requirements whilst weaning. However the volume
consumed can sometimes fall as they become
more competent eaters. This is an example of a 10
month old’s diet drinking 500ml formula milk daily.
126mg
On waking
120ml Aptamil Pepti
2
Lunch
100g Beef Casserol
e
20g Carrot sticks
70g Pureed apple +
custard
(made using 50ml Ap
tamil Pepti 2)
126mg
9 month old infant
who drinks low volume
of formula milk
126mg
Calcium per portion
76mg
201mg
63mg
ped banana
60mg
il Pepti 2
m intake
(daily hypoallergenic formula
milk intake = 500ml)
Mid morning
20g Finger food: Ch
op
33mg
Before bed
200ml Apta
m
Total calciu
6mg
64mg
Typical formula fed
10 month old infant
Breakfast
15g Fortified porri
dge
100ml Aptamil Pepti
2
pear slices
• Vitamin D: which is critical to bone health as it
stimulates bone maturation and together with the
parathyroid hormone regulates calcium metabolism
and promotes calcium absorption through the gut
and kidneys.6 Low vitamin D status impacts on calcium
absorption.
The calcium bioavailability of many calcium fortified foods
is 30-40% and hence comparable with that of milk (32)%,
however in some fortified beverages, calcium tends to form
a calcium salt which settles to the bottom of the carton.
They may therefore require a vigorous shake prior to use to
help the calcium salts disperse.8
In those infants who are unable to meet their calcium
requirements from diet a prescribed or shop-bought calcium
supplement is recommended.
(daily hypoallergenic formula
milk intake = 350ml)
This is an example of an infant whose formula intake
is 350ml daily. This illustrates how formula can be
used when making porridge, breakfast cereal, main
meals and desserts to increase overall formula
intake and ensure adequate calcium intake.
Total intake of formula = 550ml daily
Mid afternoon
80ml Aptamil Pepti
2
Dinner
15g Hummous
38g Toast soldiers
(1 x slice calcium fo
rtified bread)
65g Rice pudding
(made using 50ml Ap
tamil Pepti 2)
Before bed
150ml Aptamil Pepti
2
Total calcium intak
e
735mg
32mg
51mg
6mg
179mg
32mg
95mg