Do not confuse lactose intolerance with cow’s milk allergy

I have written about this topic before, but constantly get reminded through social media posts, how much misconception about still exists and how people who are not specialist in this field allow themselves an opinion that can be so dangerous. I saw a Instagram post by a vegan advocate, talking about lactose intolerance being a primary motivation to why breastfeeding should be motivated and cow’s milk formula not be used but rather a plant-based alternative. In addition, this post makes the statement that many babies are born with a lactose intolerance. Whilst we should motivate ongoing breastfeeding for many many reasons, this is not one of them and again highlights the confusion of distinguishing between lactose intolerance and cow’s milk allergy.

Congenital lactase deficiency (i.e. being born with a lactose intolerance) is an extremely rare genetic condition and in my career as paediatric dietitian working in allergy/intolerances for 23 years, I have only ever seen 1 baby with this. The primary source of energy in breastmilk is lactose (also in standard formula), so if a baby has a congenital lactase deficiency they can not tolerate breastmilk or standard formula due to the lactose content. Conversely primary lactose intolerance is common, but only develops in children from around 3 years of age and affects certain populations more (i.e. Africans, Asians). So the latter develops usually when a baby is off breastmilk or formula. Typically children with primary lactose intolerance can tolerate cheese and some may also tolerate yoghurt, but can not tolerate milk as a drink. Secondary lactose intolerance is more common in babies as a result of chronic diarrhoea (this can occur as a result of a bug or a chronic disease affecting the gastrointestinal tract) where the mucosa is damaged, which leads to an intolerance to lactose that is totally reversible on treatment.

A lactose intolerance is non-immune mediated, whereas a cow’s milk allergy is an immune mediated disorder and is related to an allergic reaction to the protein (not lactose, which is a carbohydrate) in cow’s milk. Cow’s milk protein consumed by the mother can transfer through breastmilk and can ins some cases lead to a reaction through breast milk. This has nothing to do with the lactose content of breastmilk (which can not be changed in mothers milk, even with a vegan diet). For these babies, under the supervision of a dietitian and an allergist/gastroenterologist a maternal elimination diet should be considered and if breastmilk is not available a hypoallergenic formula should be provided. There was a suggestion that there are plenty of suitable plant alternatives available for babies, but that is not necessarily the case and proper advice should be sought as this may differ between countries. For example, no over the counter plant milk (note not formula) is currently suitable (in any country) as a primary drink for any baby < 1 year of age and care should be taken if used > 1 year of age as they are low in protein and lacking many of the essential micronutrients. Soya formula is available, but in the UK about 50% of babies with a delayed cow’s milk allergy will also be allergic to soya. Rice formulas are available in some European countries (but not in the UK), so this is not always an alternative.

Whilst it is really important to think about sustainable choices when feeding the future generation and moving towards an increase in plant-based sources, it is so important that parents get the right advice around infant formulas (allergic or non-allergic) if breast milk is not available. Not all advice provided is correct and can have a negative nutritional impact.

High Protein Intake in Early Childhood – Should I worry or not?

For adult nutrition, following a high protein diet has become very fashionable with the increasing popularity of the paleo diet. There has been a lot of scientific debate on the efficacy of that diet in adults, I am however more worried about this trend blowing over into nutrition in early childhood.

Over the last year, more and more parents have been asking me about the value of increasing protein intake in their babies complementary food and I have seen also some of the baby food company advertising their food as “high in protein”, as if this is a good thing. Firstly, I want to say, that today’s blog entry is for healthy babies, without any underlying medical diagnoses, where there may be a need to alter protein intake. The latter need to get individualised help from a paediatric dietitian. 

I am just going to come out with it – high protein intake during early childhood is NOT good! In breastmilk  about 6% (give or take) of the energy comes from protein. Breastmilk is the ideal source of nutrition in babies and recommended alongside solids until 2 years of age. So breastmilk is in fact low in protein, high in fat and carbohydrates and this is the ideal source of nutrition for babies. More than 10 years ago, studies started to emerge that babies who were on infant formulas, which then had a higher protein content, had a higher BMI in later life, than breastfed children. As a result ALL standard infant formulas dropped their protein content since then. It was initially thought that the link between higher protein intake and obesity in later life was related to milk protein specifically, but over the last 5 years, it has transpired from research, that it is high protein intake per se (so that means any protein from meat, fish ect) that is linked to obesity in later life. How does excessive protein intake lead to obesity in later life? The “early protein hypothesis” has been generated to try to explain this phenomenon. It is thought that high early protein intakes increases plasma concentrations of insulin-releasing amino acids, which in turn stimulate the secretion of insulin and insulin-like growth factor I, which enhance weight gain and body fat deposition, as well as the later risk of obesity, adiposity, and associated diseases.

I am sure that you are now wondering, what is high protein intake?  Research points towards a protein intake within the first 2 years that exceeds 15%  being linked to obesity. So what does 15% of protein mean? If you had a meal of 100 kcal, it should ideally not contain more than 3.75 g of protein (1 g = 4 kcal and 3.75 g = 15 kcal). I have looked through many of the commercial foods and quite a number of these, exceed this threshold. Is this against the law? No, not at this stage, as companies in the EU can go up to 5.5g of protein per 100 kcal (that would be 22% of energy from protein). This legislation is from 2006 and was put in place before all of this research emerged of the impact of high protein intake. I understand, the EU is due to update this in 2020.

So what would I practically suggest – first of all monitor the protein content in baby foods (see above guidance), AND do not fall for any marketing saying “high protein is good in babies”. If you have a pouch that is higher in protein, you can bring down the ratio by adding vegetables/carbohydrates to the pouch. When you cook your own food, try not to exceed the following ratios 1:5 protein and 2:5 starchy foods and 2:5 veg/fruit. There is also no need in a young babies on solids to limit fat intake, remember breastmilk is very high in fat.

I hope that this provides parents with some clarity on the topic.

Home-made versus ready-made meals for babies and toddlers

I have touched on this topic with previous posts, but it remains an extremely common question that I get from parents whether home-cooked foods are better than ready-made meals.

Of course as a dietitian, I will always prefer home-cooked foods to ready-made meals, as this does not only allow for a lot of flexibility with meal variety, but also ensures that babies and toddlers are exposed to an environment where cooking occurs and where they eat the same as the rest of the family (minus salt and sugar). Role-modelling around food, meaning that a baby/toddler observes that the foods that he or she is eating is also being consumed by other family members is so important.

However, there are  other reasons why I prefer home-cooked foods, which relate to the variation in texture and also the fact that home-cooked food is not sterile and therefore seems to have a positive impact on the gut microbiota (the bugs in the small and large bowel). Most of the baby foods come in 3 stages for texture, they come in pouches and the recipe of the meals remain exactly the same. Whereas home meals, even with the similar ingredients, often have slight variations in taste and texture. I frequently see children in my clinic, that will not eat home-cooked foods because its not as finely pureed as ready-made meals or they do not cope with the texture of stage 2 or 3 meals.

Lastly, there has been a worrying trend in ready-made foods for babies and toddler, with the addition of fruit into savoury meals. These are also often not spoon fed, but given to babies to suck on, because this is faster and cleaner. This is now starting be addressed internationally and the first position statement has been published in Germany against using excessive fruit in ready meals and I am hoping this will lead to also a position statement in the UK. Sweet is a primary taste that is well developed in babies because breastmilk and formula milk contains lactose which is sweet and signals energy. Babies and toddlers will  prefer sweet flavours and by having savoury meals with sweet fruit in them, they do not learn to eat the more bitter tasting vegetables and savoury tasting legumes and meats. Also, babies need to learn to feed themselves and this is a messy process and should not occur through sucking a pouch, which is clean and they know how to suck, but need to learn to chew and take a spoon.

Of course, we all live in the real world and I know it is impossible for all parents to cook for their baby or toddler all the time and when you go on holiday, parents also need a break from cooking. So for me its finding the happy midway of doing some cooking at home (there are usually foods you cook for yourself that can be used for babies – minus sugar and salt) and complementing this with ready-meals as it suits your lifestyle. Have a look at the ingredients of the ready-made meals and avoid savoury meals with sweet fruit added to them and go for combinations of foods that your baby/toddler is likely to be exposed to at home as well. Vary the texture by adding vegetables or meats/legumes to the ready-made meals and also offer age appropriate finger foods. Most importantly, feed the ready-made meals with a spoon and avoid for your baby/ toddler suck their food from a pouch.

Keeping your Baby and Toddler Hydrated in this Hot Weather

We have been having exceptionally hot weather in Europe and unlike other years where this may last just for a day or two, this seems to be going on and on.

Babies/Toddlers (as well as elderly) are at higher risk of becoming dehydrated, because of their smaller bodies they have less body fluid reserve and their surface area to volume ratio is higher. Its important therefore to recognise the symptoms of dehydration early, which include:

  • seem drowsy
  • breathe fast
  • have few or no tears when they cry
  • have a soft spot on their head that sinks inwards (sunken fontanelle)
  • have a dry mouth
  • have dark-yellow pee (less wet nappies)
  • have cold and blotchy-looking hands and feet

Firstly it is important to keep them out of the sun and clothe appropriately with light, breathable clothing. Ensure also that your baby is not wrapped up too hot when sleeping.

For breastfed babies < 6 months of age, the ideal is to increase the breastfeeding frequency, which often occurs naturally, as babies signal when they need more fluid. For formula fed babies, they will need more formula as well during hot weather and again, most babies will signal this automatically.

For babies over 6 months of age, cooled boiled water should be offered frequently in hot weather. I often get asked how much they should have, which very much depends on the weight and age of the baby. Most babies > 6 months of age weigh > 5 kg, so that means you are looking at 100 ml/kg of total liquid (that is milk and water) to maintain hydration, during very hot weather this can increase to a total 120-130 ml/kg of water. This is just a rough guide as some children want more than that and some are fine just with 100 ml/kg. It is therefore important to monitor their hydration status.

For toddlers, milk of course is not such a prominent liquid in their diet as for babies. It is therefore really important to ensure that they consume sufficient additional liquid, ideally in the form of water. Fluid requirements are calculated as follows:

  • first 10 kg = 100 ml/kg and for the following 1 kg its 50 ml/kg. So a toddler of 13 kg would require 1150 ml liquid per day.
  • Remember though that food also contains water and contributes to the total fluid intake

I do have children that refuse to drink water and although I am not a fan of fruit juice, in this hot weather its more important to keep them hydrated, so I usually suggest (in cases that refuse to drink plain water) to flavour water with a little bit of fruit juice (1:5 dilution) and/or you can also try fruit ice lollies (blending fruit with water). In addition, offer plenty of juicy fruit (i.e. water melon) and vegetables that contain water (i.e cucumber).

If ant any stage you are worried about your baby or toddlers’ hydration status, please seek professional medical help.

….and more on Cow’s Milk Protein Allergy

In spite of a lot of advances in food allergy, the misconceptions amongst parents as well as healthcare professionals continue.  One of the biggest area of confusion is that of non-IgE mediated cow’s milk protein allergy, affecting the gastrointestinal tract. As there are no simple tests (and I mean really NO tests, no matter what the internet says) that can confirm this allergy, it remains an allergy that is based on identifying the symptoms followed by a trial elimination diet and then reintroduction to confirm/disprove the allergy.

I have been involved with an international team to publish the new iMAP guidelines, which provides simple guidelines for healthcare professionals (and parents) for this delayed form of cow’s milk allergy. Allergy UK has been supporting the distribution of these guidelines in the UK and has some useful tools (supported by the UK authors), which can be downloaded from their site.

In addition, Dr. Adam Fox, one of the authors also did a very useful BBC radio interview that many parents may find useful. The section on cow’s milk allergy starts about 7 minutes into the link.

Feeding Routines in the Weaning Infant

I always struggle to answer parent’s questions about feeding routines in babies that are going through the weaning process (when solids are introduced). It would be lovely if there was clear scientific evidence for what exactly to do when solids are introduced but the truth is that there is no clear evidence of what to advise parents, as babies are different sizes, have different growth velocities and different hunger and satiety patterns. I also think that it is really important to take into account other siblings and meal patterns at home, when thinking about a baby’s routine.

The best way to address this question (I think) is to start by thinking what we know in regards to baby’s routines:

  1. In the early stages of weaning the majority of nutrients will come from breast milk or formula and this will remain an important part of the diet until around 1 year of age (give or take)
  2. After 6 months of age babies will need some of the key nutrients to come from food and this includes iron rich foods
  3. The responsive feeding style has been shown to be the most effective in early childhood (see blog on feeding difficulties). To be responsive as a parent around mealtimes, means you listen to their hunger and satiety cues – if they want to stop you stop if they want more you give more (it’s not driven by specific portion sizes)
  4. It is important to broaden the variety of tastes and textures early on, because > 10 months of age it becomes much harder introduce new foods and increase textures

So, when you start weaning, I usually suggest keeping the milk (breast or bottle) routine exactly the same and introduce a midmorning solid. Initially this may just be a couple of teaspoons and you may find that these initial vegetables/fruit do not displace any feeds. It is important to know, that fruit and vegetables do not replace the energy, fat and protein rich breast milk or infant formula. You will soon see whether your child wants to progress faster (i.e. they want bigger portions, they exited about the meal and do really well with new tastes/textures). If your baby is progressing well, you can introduce 2 meals per day quite soon (even if this is within the first week of weaning) and at this stage you may find that they start signalling that they may not want to drink all of their milk. You an follow their lead at that stage and reduce the breast/bottle feed that they are not that interested in.

Introduce iron rich protein foods soon after 6 months, which then allows you to go onto 3 meals per day. At this stage, your baby should naturally signal that they want to cut down some of their feeds, so you may end up with a routine as below:

Early morning breast feed/bottle




Breastfeed/bottle – depending on the age of the baby you could cut out either midmorning or mid-afternoon feed and replace with a snack (i.e. yoghurt and fruit)



I do sometimes have parents that report that their baby eats big volumes and do not want to cut down any breast/bottle feed. If this happens, it is worth to check growth and see whether your baby is moving up excessively in weight gain. If this is the case, I would recommend you talk to a dietitian to see what can be done to prevent early onset overweight/obesity.

Should my baby have a probiotic?

There is most probably not a week that goes by without parents asking me about probiotics for their baby, either for general health or for specific gastrointestinal conditions. I have just come from the a Gut Microbiome Conference in Paris, so it seems fitting to write about this topic in this blog entry.

So, the bacterial flora constitute 90% of the total number of cells associated with our bodies and only the remaining 10% are human cells. So in fact, we are more bacteria than human! There is not doubt in the scientific community that the microbiota of the gut is part of the answer to our health and also the cause of many illnesses. There are numerous studies indicating an abnormal bacterial flora in children with allergic disease, inflammatory bowel disease and even specific trends in children that are under/overweight have been found. This all sounds very exiting, but here is where the problem lies: your microbiota changes with age, diet, genetic background, antibiotic use in early childhood and environment. So that means, although your baby may have about 40% overlap in bacterial flora with another baby, the rest is unique to them and is determined by the factors mentioned above.  I often have parents that have have had their child’s bacterial flora evaluated at very high cost, that ask me what to give in regards to probiotics, but disappointingly I have tell them that I do not know as I do not know what is “normal” for their child.

In disease (i.e. allergy, reflux, inflammatory bowel disease, irritable bowel disease) they are starting to identify target strains that have specific functions, that is very exiting and many of us working with dietary interventions in children are starting to use these products, BUT I always say to parents that it may not always provide you with this magic symptom relief.

So, what can you do? First of all, the more diverse the diet (in particular with fruit/vegetables and grains) the more diverse the gut bacterial flora and diversity has been linked to health. If you do want to give a probiotic to a healthy baby as a general rule of thumb you would aim for Bifido strains for < 6 months old as this is the predominant strains in a breast fed child and then complementary foods increase Lactobacilli strains increase, so then using these strains may be more useful. Go for a reputable brand, that has actually in what it is supposed to have and if your child has a specific diagnosis, consult your dietitian about what the best strain is to use. An important message to get out, is that strains of probiotic are specific so one may help with one condition but not with another. Another important message is that when your child is on an antibiotic, to choose a probiotic that is resistant to the antibiotic, otherwise the well-meant probiotic will also be killed by the antibiotic.

I leave you with these thoughts and most importantly, that healthy eating also creates a healthy gut.

Health Millet Bars for Toddlers

Ingredients (milk, egg, soya, gluten free)

100g ground nuts (you can grind any nuts you like)*

100g millet flakes

2 tablespoons honey

1 mashed banana

 * this recipe is not suitable for children with multiple nut allergies, but if you have been asked to introduce selective nuts, its ideal and you can only  use the nuts your child tolerates


Mix all together and press with your fingers/spoon in a baking paper lined tray. This recipe is sufficient for pie pan and if you double it you can fill a baking tray.

Bake for 20 min at 180C and cut in 2cmx5 cm squares

Size of a child as trigger of feeding difficulties

I promised last week that I would expand on each trigger of feeding difficulties. I will start with size – or growth of a child, which next to texture transitioning is one of the biggest causes of feeding difficulties.

First of all, it is important to get your child’s growth assessed on a regular basis. I want to define what is growth, because most people just think of weight, but in fact growth encompasses weight, length/height growth and in a child < 2 years of age head circumference. You can not assess how a child is growing only by looking at their weight, because the length of a child gives you important long term information on growth and so does a head circumference in the young. For example if your child’s weight has dropped a centile but the height is continues to grow well, then this is  much less worrying as your child may come from a taller skinnier family and this is genetically normal for your child. So if there is one message that comes out from today’s blog entry, is to get a length/height and head circumference (< 2 years of age) done before you start worrying that your child is not growing.

Now, why is growth a trigger for feeding difficulties? Usually if somebody tells a parent that their child is not growing it hits a very sensitive nerve that goes to the core of parenting. No parent can be blamed for not taking this personally! The knee-jerk reaction is to immediately start correcting this by feeding more food and increasing the frequency of feeding intervals. It makes sense that more food equals more energy and protein intake which means growth. However, your child may not want to have more and eat more frequently, which then leads to them refusing food, the parents becoming more distressed as they worry about their growth and the more distressed they are the harder they try, the more the child refuses……so you can see a cycle of feeding difficulties starting.

I would like to give some simple tips, but this does not replace professional advice.

  1. Enrich the food that your child is currently eating happily with cheese, cream, pureed lentils and other energy and protein rich foods. Ensure that you give full cream yogurt, provide a spoon of nut butter in the porridge your child is having or make a fruit smoothie with yoghurt and almond butter for example. Gaining weight is not just about energy but protein as well, so adding just oil is not going to do the trick.
  2. Do not increase sweets and chocolates – these are empty calories and do not contribute hugely to catch up growth. Food increases catch up growth which is more balanced and also for the future better for your child.
  3. Ensure that your child has sufficient vitamins and minerals which are co-factors for growth. This means, your body needs them to metabolise the energy they are consuming.
  4. Keep meal times to 30 min and no longer than this!
  5. Offer a manageable portion – this is psychologically important for parent and child
  6. If the can self feed – ensure that they have foods that are higher in energy and protein that they can self fed – cheese strips, falafel, home-made chicken strips, bread sticks and hummus, avocado and oat cakes as snack ect. This is often more successful.
  7. Respect your child’s signals of hunger and satiety – if they signal they are full, stop feeding
  8. Never force feed or feed when they are unhappy and crying


Feeding difficulties in Children

Every week I see children with feeding difficulties of varying degree in my clinic. What I can tell parents is that it is common, you are not abnormal and that it is very difficult dealing with a child that does not want to eat. I do want to focus a couple of blog entries over the next weeks on this topic, as I think there are some simple tips that may help and most importantly its you as parents want to know when do you need to see a healthcare professional.

Lets start with what are feeding difficulties.Generally if a child has one (or a combination) of the below they are classified as having feeding difficulties

  • extended mealtimes (if they take > 30 min)
  • sealing of the mouth/pushing food away
  • gagging on solids
  • spitting food out – every meal and all foods
  • dream feeding – so refusing to feed from the bottle if awake and only taking it whilst asleep

There is a lovely acronym summarising all triggers for developing feeding difficulties and it is called “STOMP”.

S – Size: the natural response to a child not achieving optimal growth is to try harder, to feed more, increase volume or frequency of foods and all of this leads to an increase in stress in mealtimes and as a result feeding becomes something your child (and you) want to avoid.

T – Transitioning: transitioning from breast to bottle, from puree to textured foods can can also lead to problems. For example the first time you provide some lumpier textures your child gags (which normally looks like they are choking but is not that bad), you get a fright and as a result do not move on with textures. If textured foods are not introduced by 10 months of age, it becomes very difficult as a critical window of opportunity has been missed.

O – Organic disease: there are many medical reasons why a child does not want to feed. That may be related to an anatomical problem with swallow/stomach, reflux or food allergies. It is therefore important to ensure that medical causes are ruled out. I will in a future blog highlight exactly the medical “red flag sign” that should not be ignored with feeding difficulties.

M- mechanistic feeding: the most common question from parents is that they want an exact schedule (including timing) for when their child should have a bottle, when they should have a snack and meal. So meal times become “mechanistic” rather than responsive to your child’s needs. Feeding a child or lets say trying to feed a child when they are not hungry but just according to the clock may also feed into the development of a feeding difficulty.

P – post traumatic: this can happen for example with a severe allergic reaction. For example your child had some egg, started swelling up in the mouth, was rushed to the emergency room and as a result is not only refusing egg but any foods that have a texture like egg. Another example is chocking (and I mean really choking) on food, which is very frightening for parents and the child and can put children off having pieces in future because they are scared of choking.

I will write next week on who size can impact on feeding difficulties and what you can do