After dietary assessment recommend nutrient supplements for vegan diets which are found to be nutrit

(i) Food allergies. Adverse food reactions are divided into two general categories: food intolerance and food hypersensitivity. An allergic reaction to a food involves the immunologic system. The incidence of food allergies has been estimated at 8% in the first year of life, and decreases as children get older; however, most further qualify it to be in the 1% to 2% range (Bock, 1987). The risk of developing food allergies is largely related to genetic predisposition and the age at which the food is introduced, with the chance of sensitization greatest in the first year of life. Young infants are especially prone because their immature intestinal system is more permeable to absorption of food allergens and lacks local immune defences (Burks and Sampson, 1993). Most allergens are proteins of large molecular size, therefore food allergy commonly presents in infancy with the first introduction of milk, egg or peanut (Burks and Sampson, 1993). These three foods, as well as soy, nuts and wheat, are responsible for about 95% of food allergies in infants (Bock and Atkins, 1990). It is rare for an infant to have allergies to more than two or three foods (Bock and Atkins, 1990). In an exclusively breastfed infant, the source of these allergens can be the mother's diet. The proteins pass into her breast milk and thus are ingested by the baby (Jakobsson 1991).

Diagnosis of food hypersensitivity requires a careful history to exclude other causes of adverse food reactions, selective skin prick testing or radioallergosorbent test (RAST) (when IgE mediated disorder is suspected), appropriate removal of the food from the diet, and a subsequent challenge test (Bock and Sampson, 1994; Burks and Sampson, 1993).

Treatment of food hypersensitivity involves avoidance of foods proven to cause symptoms. Food-related allergies tend to disappear with age, therefore rechallenging with the offending food is recommended at regular intervals (Bock, 1986). Allergies to peanut, nuts, wheat, fish and seafood are the most severe and tend to be lifelong (Burks and Sampson, 1993). In the case of multiple food allergies or severe reactions to food, the assistance of a dietitian with expertise in food allergies may be beneficial.

The ability to prevent food hypersensitivity is being debated. Exclusive breastfeeding for at least 4 months has been shown to decrease the risk of allergy in infants at increased risk of food allergies. The use of protein hydrolysate formulas and the delayed introduction of solid foods have been studied for prophylaxis of food hypersensitivity. Many of the studies are conflicting. (For further discussion of this topic, see the sections on breastfeeding and the prevention of allergies, and protein hydrolysate formulas.) A single recent study showed that exclusive breastfeeding, or feeding a formula containing a partially hydrolyzed whey-hydrolysate, was associated with lower incidence of atopic disease and food allergy compared to feeding soy or conventional cow's milk formulas

  • Chandra, 1997).
  • ii) Colic. Colic occurs in approximately 13% of infants independent of how they are fed (Lehtonen and Rautava, 1996). Despite a number of theories, the cause of colic remains unknown. It typically begins before 3 to 4 weeks of age and lasts until the infant is about 3 to 4 months of age. Although the cure, or permanent treatment, for colic is unknown, cuddling, rocking, stroking and massaging are common ways to soothe infants with colic. Early introduction of solid foods has not proven beneficial while the replacement of cow's milk protein has met with varying success (Lehtonen and Rautava, 1996; Hill et al., 1995). For the breastfed infant, overfeeding or an overactive milk ejection reflex may cause symptoms like colic (CICH, 1996). Gulping of milk may lead to excessive air swallowing or excess ingestion of lactose from foremilk (resulting in mild carbohydrate malabsorption) which may lead to abdominal pain. In such cases, changes in feeding routine and pattern are worth considering.

Various pharmacological treatments have been tried but none has been proven to be of definite benefit. Simethicone, a defoaming agent, has been most extensively studied. It is said to accelerate the passage of intestinal gas by decreasing the surface tension of gas bubbles.

Controlled studies show varying results, although most did not show any benefit (Becker et al., 1988; Sethi and Sethi, 1988; Dugger and Inchaustegui, 1963; Danielsson and Hwang, 1985). Most recently, Metcalf et al. completed a randomized, placebo-controlled, multicentre trial which demonstrated that simethicone was no more effective than a placebo (Metcalf et al., 1994). Because colic is associated with gastrointestinal discomfort and certain herbal teas have been cited as having antispasmodic activity, herbal teas have been used to treat colic. Weizman and colleagues recently demonstrated in a prospective double-blind study that a herbal tea containing chamomille (Matricaria chamomile), vervain (Verbena officinalis), licorice (Glycyrrhiza glabra), fennel (Foeniculum vulgare) and balm mint (Melissa officinalis) appeared more effective than a placebo in improving infant colic (Weizman et al., 1993). This study was limited in that the measure of outcome was based on parents' subjective evaluation and the study duration was short. Further studies are needed before this intervention can be routinely recommended since the safety of some herbal teas if taken in large amounts has not been established.

(iii) Constipation. The definition of constipation in early childhood is elusive (Forsyth et al., 1985). Stool patterns vary normally from child to child. In infancy, true constipation is infrequent. There is wide variation in the "normal" number of bowel movements per day, ranging from a bowel movement days apart, to one after each feeding (Rappaport and Levine, 1986). Normal bowel function occurs even when an infant appears to be in extreme discomfort as evidenced by straining and reddening of the face. There is no evidence that inadequate fluid or carbohydrate intake is the cause of constipation in infants; nor is there evidence that treating constipation with fruit juices or corn syrup is efficacious. Educating parents about the wide variation in normal bowel function seems essential for avoiding the overtreatment of normal variants.

Hard and painful bowel movements signal a mild to moderate problem in bowel function, whereas abdominal distention requires further work-up and medical intervention. The use of prune juice (with its high sorbitol content) and/or increasing the fibre content of the diet may be helpful for infants older than 6 months. A varied intake of fibre-containing foods such as whole grain breads and cereals, fruits, vegetables and cooked legumes is suggested rather than the routine use of fibre supplements (Agostini et al., 1995). There are no data regarding the amount of fibre needed for normal laxation during the first 2 years of life. Recent recommendations on dietary fibre intake for children (age plus 5 g/day) apply to children older than 2 years (Williams et al., 1995). These recommendations to a large extent reflect current dietary intake of fibre by children in North America. They are not based on evidence of disease prevention. Concerns related to increased consumption of fibre in infants and toddlers include a possible decrease in caloric intake resulting in inadequate growth and development, decreased bioavailability of minerals, and an increase in intestinal gas and abdominal discomfort. Studies in older children and adults suggest that these concerns may be unfounded (Dwyer, 1995).

  • iv) Dietary fat. The optimal amount of fat in the diet is related to the infant's stage of development and requirement for energy. Energy and nutrient requirements are particularly high in the first 2 years of life. Thus, dietary fat restriction would potentially compromise both energy and essential fatty acid intake and is not advised. There is no evidence that restricting fat intake in children reduces illness in later life or provides benefit to children during childhood (Health Canada and CPS, 1993; Health and Welfare Canada, 1990a).
  • v) Dental caries.
  • a) Fluoridation supplementation. Fluorida-tion of the water supply is the most effective, cost efficient means of preventing dental caries. In areas with low fluoride levels in the water source, fluoride supplements are recommended. An increase in the availability of fluoride (fluoridated water, foods or drinks made with fluoridated water, toothpaste, mouthwashes, vitamin and fluoride supplements) has led to an increasing incidence of very mild and mild forms of dental fluorosis in both fluoridated and non-fluoridated communities (Clark, 1993a; Levy, 1994). The effect of dental fluorosis is cosmetic only, ranging from white striations or specks to areas of pitting or brown-gray staining. The teeth remain resistant to caries and there are no known associated health risks.

This sign of excess fluoride intake has led to modifications in fluoride recommendations such that fluoride supplements are no longer recommended from birth, and doses have been decreased during the first 6 years of life. The difficulty lies in knowing how far to lower fluoride supplementation without jeopardizing the benefits of caries prevention. The diversity in drinking water supply and dental hygiene practices in Canada, and the lack of comprehensive epidemiological data, have made it difficult to reach agreement on the best way to provide the right amount of fluoride to all Canadian children.

Recently the Canadian Paediatric Society (CPS) and the Canadian Dental Association (CDA) participated in a consensus conference organized to unify an approach to fluoride supplementation for infants and children living in Canada. The proposed new recommendations (CDA, 1998) would replace the existing CPS (CPS, 1995) and CDA (Clark, 1993) recommendations; they include a decision-algorithm for use by health care providers as well as a new recommended dosage schedule of daily fluoride supplementation (see Table 1). The goal is for all organizations to work together to implement this uniform fluoride supplement schedule in Canada.

As more information becomes available from monitoring trends in dental fluorosis, the optimal timing and dose of fluoride supplements needed to prevent dental caries, and avoid dental fluorosis, may require further revision. It should be noted that "ready-to-serve" infant formulas in Canada are not fortified with fluoride.

Table 1. Dosage Schedule for Dietary Fluoride Supplements (mg/d)

If fluoride concentration of principal drinking water source is:

Birth - 6 mo none none

Canadian Dental Association. Personal Communication. 1998

  • b) Nursing bottle syndrome. The etiology of nursing caries is multifactorial. Nursing bottle syndrome has been attributed to giving a bottle of sugar-containing beverage during sleep time or to pacify an infant, bottle feeding past 12 months of age and the use of sweetened pacifiers. Bathing teeth in nutrient-containing liquids (milk, fruit juices and fruit drinks, or carbonated, sugar-containing beverages) provides a continuous supply of nutritional substrate for dental bacteria to proliferate. This may result in carious teeth. When an infant is asleep, liquid can pool in the mouth, and salivary flow and oral cleaning are diminished (Herrmann and Roberts, 1987). Children who fall asleep with a bottle in their mouth are at significantly greater risk of caries than infants who discard the bottle before falling asleep (Schwartz et al., 1993). The use of bottles or pacifiers dipped in sugar, syrup or honey during the day or night can also cause damage to the infant's deciduous (primary) teeth (Fomon, 1993). The effectiveness of preventative dental counselling in inducing dietary change has been questioned; however, for the prevention of nursing caries it seems clinically sensible to recommend counselling parents to avoid nocturnal and long-term use of baby bottles containing liquids other than water (Lewis and Ismail, 1994).
  • vi) Gastroenteritis. Oral rehydration therapy (ORT), combining the use of oral electrolyte solutions (OES) with early refeeding, has proven to be safe and efficacious for restoring and maintaining hydration and electrolyte balance in infants with mild and moderate dehydration, including those with vomiting (US Department of Health and Human Services, 1992). Oral electrolyte solutions containing specific concentrations of carbohydrate, sodium, potassium and chloride promote fluid and electrolyte absorption, while fluids such as juices, carbonated soft drinks, tea, sports beverages, Jello or broth do not. Human milk is well tolerated during diarrhea and may reduce its severity and duration (Haffejee, 1990); therefore, breastfeeding should continue throughout the diarrhea with additional fluids given as OES. Early and rapid refeeding should occur as soon as rehydration is achieved and vomiting stops (ideally within 6 to 12 hours of beginning treatment). Infants treated with OES and early refeeding have reduced stool output, shorter duration of diarrhea and improved weight gain (Brown, 1991; Brown et al., 1988). Routine change to lactose-free or diluted feedings is unnecessary in well-nourished infants with mild to moderate gastroenteritis (Brown et al., 1994). The Canadian Paediatric Society Nutrition Committee (CPS, 1994b) has recently published recommendations on ORT and early refeeding in the management of childhood gastroenteritis.
  • vii) Diabetes. Insulin-dependent diabetes mellitus (IDDM) is the most severe form of diabetes and the most common chronic disease of childhood. For disease to occur; there must be genetic susceptibility and interaction with as yet undefined environmental factors, possibly viruses and foods. Early infant nutrition involving a lack of, or short duration of, breastfeeding and early exposure to cow's milk have been implicated but the case-control data show considerable variation and the evidence implicating the cow's milk protein, bovine serum albumin (BSA) has been seriously challenged (Ronningen et al., 1995; Atkinson et al., 1993, 1994). A recent meta-analysis showed that although there is a weak effect of lack of breastfeeding and early exposure to cow's milk-based formulas, the only studies where prospectively recorded data were available showed no association with IDDM (Norris and Scott, 1996). Results from an ongoing study in very young genetically high-risk siblings and offspring of persons with IDDM showed early exposure to cow milk was not associated with diabetes autoantibodies (Norris et al., 1996). Studies in diabetes-prone animals indicate there may be several food diabetogens, and that timing and duration of exposure is important. In diabetes-prone rats, wheat and soy are potent and consistent promoters of diabetes, whereas the diabetogenic potential of cow's milk varies greatly from batch to batch; exposing these animals to known diabetogenic diets as late as puberty can still induce diabetes (Scott, 1996). Thus, long-term exposure to food diabetogens, considerably past the time of infancy, is required for diabetes to develop.

The timing of the diet-IDDM interaction in humans remains to be established. Although hydrolyzed casein-based diets are diabetes-retardant in animal models of IDDM, the use of hydrolyzed casein-based infant formulas for prevention of diabetes in high-risk human infants is not recommended because prevention of diabetes may require avoiding diabetogenic foods long past the time of infancy and these formulas are unpalatable and expensive. Knowledge of the food diabetogens, and particularly the mechanisms by which they cause diabetes, is still incomplete, making it difficult to justify dietary intervention trials in children at this time. Until more definitive data are available on the timing, duration of exposure and the exact identity of all the foods that may promote diabetes, it is inappropriate to recommend changes to infant feeding practices.

(viii) Iron deficiency anemia. Iron deficiency is most common among infants between the ages of 6 and 24 months. The major risk factors for iron deficiency anemia in infants relate to socioeconomic status, the early discontinuation of breastfeeding and include the early consumption of cow's milk, and inadequate funds for appropriate foods (Canadian Paediatric Society, 1991; Gray-Donald et al., 1990). Other high-risk groups include low birth weight and premature infants (Friel et al., 1990; Shannon, 1990), and older infants who drink large amounts of milk or juice, and eat little solid food (Feightner, 1994). The importance of preventing rather than treating anemia has been emphasized by findings that iron deficiency anemia is a risk factor for what may be irreversible developmental delays in cognitive function (Lozoff et al.,

Healthy full-term infants are born with neonatal iron stores which can meet iron needs until 4 to 6 months of age (Calvo et al., 1992; Saarinen and Siimes, 1977). At this time, the absorption of highly bioavailable iron in human milk may no longer be adequate to meet the demands for erythropoiesis. Therefore, introduction of iron-fortified infant cereals is recommended as a good source of available dietary iron at 4 to 6 months of age (Fuchs et al., 1993; AAP, 1992b; CPS, 1991). For non-breastfed infants, switching from a non-fortified to iron-fortified formula around 4 to 6 months of age would meet the need for supplemental iron. However, parents may forget or ignore the need for a change in formula; therefore, as a preventative measure, it is recommended that for non-breastfed infants, an iron-fortified formula be used from birth (CPS, 1991). Although dietary iron is not used for hemoglobin synthesis in the first few months of life, its early use contributes to iron stores and helps to prevent later development of iron deficiency. In communities where the majority of formula used is iron-fortified, the prevalence of iron deficiency anemia is very low. The perception by parents and some health professionals that low-iron formulas are associated with fewer gastrointestinal symptoms has not been demonstrated in controlled clinical trials. No difference in gastrointestinal symptoms or stool characteristics (with the exception of colour) has been detected in infants fed low-iron and iron-fortified formulas (Nelson et al., 1988; Oski, 1980).

Infants weaned from breastfeeding before 9 months of age should receive iron-fortified formula. Non-fortified formula and cow's milk are unsuitable alternatives as they contain very little natural iron which is poorly absorbed. When milk is combined with other dietary sources of iron, such as iron-fortified infant cereals, pureed liver, meat, fish, legumes and egg yolk, it may be possible to avoid iron deficiency and anemia. However, there are limited data to support or refute this estimation. After 9 months of age, when a wider variety of foods is being ingested, the introduction of cow's milk is not associated with any risk of iron deficiency. Despite recommendations to the contrary, many Canadian infants receive cow's milk or evaporated milk in the second 6 months of life because of convenience and relatively low cost. For infants of informed parents who choose not to adhere to these guidelines, one may either provide medicinal iron drops starting at 6 months of age, or screen for anemia around 6 to 8 months of age.

For children more than 1 year of age, iron-containing foods, such as those listed above, provide iron in sufficient amounts. Supplemental iron is not required unless the diet is lacking in these foods.

(ix) Vegetarian diets. With careful planning, vegetarian diets for infants and children can be nutritionally adequate (Sanders, 1995; Sanders and Reddy, 1994). For vegan infants who are not breastfed, commercially prepared soy-based infant formula is recommended during the first 2 years of life to provide adequate nutrients and energy for growth and development. For older infants, a carefully selected vegetarian diet can meet all the requirements of a growing child; however, deficiencies of iron, vitamin B12, vitamin D and energy have been reported in vegetarian children (Sanders, 1995; Jacobs and Dwyer, 1988). The guidelines presented for introducing solid foods (see Transition to Solid Foods) apply to all healthy infants, including vegans. Parents who feed their infant vegan diets in the first 2 years of life may benefit from consultation with a dietitian or nutritionist to ensure the adequacy of their infant's food (nutrient) intake, and to assess the need for nutrient supplements.

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