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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