Back to the dietitian... a routine visit, for dairy free 'Baby'

'Wow you've grown!'

is what they said to 'Baby' at our most recent appointment! Or words to that effect!

And yes, I must admit, she certainly has!

My purse has been sending me that message for some while, now - I've already had to buy her almost a complete new set of school uniform and she only started school in September!

So that was the good thing about our appointment - confirmation that 'Baby,' despite her milk allergy, is thriving well.

Must admit, there wasn't much else we gained this time, as what with the nature of 'Baby's' allergy being Non-Ige, all 'Baby's' milk challenges are carried out a home - supposedly at six monthly intervals. However, all our attempts to challenge her with baked milk recently, have been frustrated by her frequent unexplained tummy aches (which I am still trying to get to the bottom of) and by her picking up various illnesses from school. 

As I've mentioned before, you have to be well in order to carry out a milk challenge* and as her reactions to milk are mainly delayed gut-related reactions, I've no idea whether these tummy aches have been cause by accidental exposure to milk, or whether she's picked up some bug. If it is an accidental exposure to milk, it would leave her gut needing a break to heal up, and get better... so we keep waiting for a golden window of opportunity to appear! 


So what did we get up to?

1) Each time we go, they check 'Baby's' measurements. 

They weigh her. These days, it requires a much bigger set of scales:

The scales!

And they measure her height, on this height chart:

No, she hasn't reached the clock, just yet!

2) We discuss her food intake. 

This enables the dietitian to see if 'Baby' was getting the right balance of food overall. It also enables her to recalculate 'Baby's' calcium intake - to ensure that she's not missing out. The dietitian might offer some tips, on how to improve intake, if required. This was especially useful in the early days of weaning.

Stupid me, sits there at this stage, 'umming' and 'ahhing' a lot, as I try to cast my mind backwards and think about what we've been feeding our little one. Only after the appointment (DOH!), does it occur to me that next time, I should be more organised and take the following, as I think this would make things a bit easier:

• a copy of the school's three week lunch plan 

• a meal plan for a 'normal' week at home

• a more precise calculation of her daily dairy free 'milk' intake (including how much she has at school)

3) We also discuss her progress (or lack of progress) with the 'Milk Ladder,'* along with any other concerns that we might have.

At the moment, we still need to attempt a baked milk challenge every six months (assuming that 'Baby' is well), but like I said, we're still working on this one.

Originally, when we saw our first dietitian, we went through the same sort of process, but 'Baby' was weighed on a very different set of scales, and, at that time, as a breastfeeding mother, my intake was closely monitored too! We also had appointments quite regularly - at least every 6 months. However, 'Baby' being older now and having moved house to a new area, our appointments have been scaled back to yearly intervals. In fact I got the impression they were not that fussed about seeing us at all! 

I can understand why:

• She's had all the tests, both blood tests (she wasn't keen on those) and skin prick - (much more harmless)! The tests revealed nothing - except that her allergy is Non-Ige mediated*. That means she's not got the life threatening version (panic over, 'cos at one stage 'Baby's' was having some interesting rashes).

• We've been managing her dairy free diet successfully at home for a while now, so there's not all that much they can teach us there, now that we've 'learned the ropes,' so to speak! 

• There are so many children developing food allergies these days and so few allergy professionals (by comparison) that they've got quite patients already!

We only had one thing to test, but it still took up most of her arm!

So, why do we go?

Well:

• We're still hovering around step one of the milk ladder.* We thought we'd achieved this step in the summer, but then, what with various things going on; emptying our old flat for sale, family illness etc. we had a short break and then it seemed that 'Baby' was no longer tolerating the malted milk biscuits. GRRR! As, we're still hoping to work our way up the said milk ladder, I wish to keep my foot in the door (as it were) with the dietitian - in case I need to refer back to her for advice.

• I want them to keep monitoring her. Yes, we're doing okay with her at the moment, but this may not always be the case! I want to keep her on the books, to make sure she doesn't end up forgotten - like an old teddy bear, deteriorating in a dusty box in the attic.

• To get updated nutritional advice - the dietitian's handout on calcium sources has significantly more content than last year!

• Also, just on the off-chance that some new miraculous discovery could advance 'Baby's' ability to tolerate cow's milk, I want to be in there with my appointment already. After all, it took us long enough to get an appointment in the first place!!

Of course, what I really long for, is the day when 'Baby' outgrows her allergy, and a visit to the dietitian is no longer required...

* Glossary:

Milk Challenge - when you try to find out whether an allergic individual is still allergic to milk, by giving them a small amount of milk, in some form. If severely allergic, this will take place within a hospital setting. If not severely allergic, this will take place at home, according to instructions provided by your Health Care Professionals.

Milk Ladder - the term given to a structured approach which is used to reintroduce cow's milk to children with a cow's milk allergy. It is based on the premise that if children can be found to tolerate baked milk (apparently 80% can), they should consume it regularly. Their bodies may then be induced to progress gradually to accept cow's milk in other forms. As a result, they are more likely to outgrow their milk allergy. I have seen several examples of milk ladders. They all work on the same principle. My preferred version has the approach broken down into twelve stages.

Non-Ige mediated food allergy - is one that does not present symptoms immediately. Reactions may occur hours, or even a few days later. This kind of food allergy does not show up in tests but is diagnosed via food elimination, followed by a challenge, in which the suspected allergen is reintroduced.

Related Posts: 

Weaning the Dairy Free Baby - First Steps!

Dietitian time coming up!

When food challenges seem to fail...

Dietitian Time Coming Up!

It's dietitian time again soon. I must not forget to... hmm! Now let me see... I know I was supposed to challenge her again, but was there something else? 

And did she say to challenge Baby three or four weeks before I went or leave it three or four weeks before trying again? Rats! I've forgotten! Where's my notes? Surely I wrote it all down? What about my notebook on the iphone? Nope! Oh well! At least I wrote the date and time for the next appointment on the calendar. 

Such was the state of my mind one Saturday morning! 

Sometimes going to the dietitian's is a bit like going to college - you get homework!! It's fine remembering it all, if it's something to start straight away and keep going with, but it's much harder to remember when it's a few months down the line!!

So I've come up with a little check list to run through, before my next appointment:

• Write down any questions I want to ask the dietitian before I go, otherwise, in the bustle of going out, I'll probably forget them!

• Take plenty of coins - the car park charges at hospitals are atrocious - £4 last time. And now there is a Costa in the lobby, (what a shame) so of course I'll want a few extra coins there!

• Take snacks and drinks for Baby - they'll keep her happy for a bit and she's bound to get hungry & thirsty at some point (especially if we're kept waiting).

• Baby will need some form of entertainment - there's nothing worse than trying to hold a conversation with the dietitian whilst Baby's getting bored and restless. These days a Night Garden comic (they have loads of good stickers that she can do without too much help) and a few crayons usually does the trick.

• Take a notebook and pen (must remember to do this) as otherwise it's easy to forget what we've discussed and decided upon.

• Take a diary, in order to plan the next appointment - no good just writing it down on a scrap of paper, as it might clash with something else and scraps of paper get lost in my bag anyway.

• Try to calculate how much milk she is getting daily before the appointment, as they're bound to ask! Me saying: 'Hmm! Well... may be a cup at bedtime and some in her mashed potato...' etc. isn't much use to anyone! Cup sizes vary, so 'a cup' could mean anything!

• Take a rough meal plan for a 'normal' week - so I don't have to try and think back and list everything we ate!

Hopefully, if I follow my own advice, the next visit will all go swimmingly!

Weaning the Dairy Free Baby - First Steps!

There are so many things that I wish I'd learned at breastfeeding school! We only had one session and they made it appear all so easy-peasy and although I'd like to stress that I am a big fan of breastfeeding, I definitely feel that they left a few things out. One of which was when to stop!

First Step - When to stop the Breast?

The way they talked about it, I was left assuming that once you had finished your six month stint, Baby was onto solid food and off we all went - sailing into the sunset with nary a backward glance. Well they didn't necessarily give that message, but no-one discussed when or how you 'gave up' breastfeeding! 

Obviously now I know that when you give up breastfeeding is a personal choice. How you give up, I'm still not sure about - because I'm still breast feeding Baby at a time when most mothers have long since kissed goodbye to the whole affair. I did read Gina Ford's advice about replacing breast feeds with bottle feeds one at a time, but having switched to feeding on demand (in order to keep the milk flowing) I'm a bit clueless as to how you stop a demand fed baby from requesting a feed. 

Mind you, I'm not fretting over it. The reason I'm still going, is partly because I still feel I have something to give her that she can't get elsewhere; partly because she definitely still wants it and finally because I have the luxury of being at home with her. If I'd had to go back to work, it wouldn't have been so easy.

When we first discovered that Baby had a cow's milk protein allergy, at the end of her first month, I was given the option. The paediatrician was perfectly willing to write the prescription. I could there and then have switched straight onto hypo-allergenic formula and indeed Nutramigen AA was prescribed, as I was encountering problems with breastfeeding. 

However, my main reason for continuing with breastfeeding was that I was concerned about Baby's main or even only source of nutrition being some manufactured formula, which I soon discovered (when I was using it as a supplement) left strange tiny little white bumps all over the skin on her face. 

Another good reason (the way I saw it) was that I was aware that breastfeeding until six months was advised as a way of preventing food allergies arising, and, as she had one major food allergy already, I certainly wanted to do my best to prevent the development of any others!!

I had hoped that Baby would be one of the lucky ones, who grew out of her allergy fairly quickly. So I aimed to breastfeed her, until six months or until that happened. Unfortunately not having reached that particular milestone, before the magic age of six months, it was back to the special formula we'd been given, in order to introduce her to solids. 

Fortunately, we already had a formula to turn to. If you need a special formula, you will need to see a Doctor in order to be prescribed an alternative. There are several out there and professional advice is required in order to work out which is the best one for your baby. Unfortunately, finding the right formula is only the beginning, as babies can develop ideas of their own and reject it! I have heard that it can be flavoured with strawberry Nesquik, but never got around to trying this myself.

Next - Moving onto solids

To begin with, Baby seemed okay with Nutramigen mixed with her favourite baby cereal or with baby rice. There was no sign of the tiny bumps that had appeared when she had been bottle fed. I thought all was going swimmingly, until Hipp Organic thoughtlessly discontinued manufacturing her favourite cereal!! 

After that, Baby didn't seem to take to any others and eventually I gave up, as she would steadfastly refuse to accept a single mouthful! Stumped, all we could do was to offer Baby vegetable or fruit purées instead - fortunately discovering one that was bulked up with a bit of granola, which made it a bit more filling. But I was concerned that Baby might be missing essential vitamins/minerals that were only available through cow's milk and I knew that I really needed a little more professional help/advice.



Getting professional advice

Not having weaned a Baby before (let alone one that couldn't have what everyone else seemed to be having) I wanted to ensure that I was properly prepared for weaning, especially as she was still unable to tolerate cow's milk. I knew that this was still the case, because of breaches in my diet that had led to a return of the familiar symptoms. Thankfully, our GP responded swiftly to my request to be referred a dietitian. Unfortunately, some people seem to have real problems with this process and have to battle it out.

In the meantime, I read books, magazines etc. and attended local Health Visitor led sessions. I did wonder (as some people advocate baby led weaning) whether we needed to be in too much of a hurry, but it was from the Health Visitor that I learned (shock, horror) that breast milk did not contain sufficient iron for a growing Baby! 

In fact the iron content of breast milk drops from the age of six months. Formula milk is specially fortified, of course, but the ideal thing is to get them onto iron-rich foods, like meat, fairly quickly. Something else, then, that they neglected to tell me in breastfeeding school!

However, the Health Visitor was, unfortunately, not all that well equipped to help much with the dairy free aspect of weaning. I was a bit disappointed with the Health visitor's lack of knowledge, especially when you think that 2% or 3% babies will experience problems with cow's milk. In fact, there were at least two other woman in our village (whose babies were the same age as mine) who also suffered from the same problem.  It was just as well, therefore, that Baby and I had the appointment with the Dietitian lined up.

The Dietitian was excellent, she offered advice on weaning Baby, but didn't neglect me as a breastfeeding mother. The Dietitian was also able to offer me another alternative, when I mentioned Baby's lack of enthusiasm for Nutramigen. She told me that babies start to develop the ability to detect bitter tastes around six months of age. This was actually very useful, when our ancestors were hunter gatherer types, because bitter plants are often poisonous. However, breast milk is very sweet apparently and Nutramigen not so. No wonder Baby rejected it - she's obviously inherited my sweet tooth! 

The Dietitian's answer was to try another formula. This one, PaediaSure Peptide, I plucked up the courage to try myself. It was vanilla in flavour but left a dry chalky feeling on my tongue and made me feel thirsty. Not surprisingly, Baby rejected this one too! For her, only breast milk would do! 

Alpro Junior Plus 1 has a lot in it!

More recently, this has begun to change - now she's that bit older we have introduced her to Alpro Junior Plus 1. I was hesitant at first, partly due to my own intolerance to soya milk, but also because there have been health concerns about soya milk. Baby enjoys this as a milk drink and has had it on cereal, although she prefers her cereal dry! As it is fortified with essential vitamins and minerals, there is less worry about lack in her diet. However, she still really prefers the Boob!

Prepared to support my decision to breastfeed, the Dietitian quizzed me carefully, to find out how often and for how long Baby was breastfed. She checked to make sure I was getting enough calcium and then she dropped another bombshell - Breast milk contained very little Vitamin D and therefore baby was going to need drops. Why didn't they teach that one in Breastfeeding School?

We were recommended to use Abidec - they produce vitamin drops for infants as well as children and are quite widely available. However, be warned! The infant drops are made with peanut oil and although the manufacturers remove the protein, Baby seemed to develop a reaction to them. 

It took some time to for the reaction to develop and longer to work out what was causing the problem. This reaction is, I believe, most unusual. Now that Baby is over the age of one, we could use Abidec's other drops which are fish-based, but we haven't tried those  just yet. It was just as well that we heeded another piece of advice, which was to completely avoid nuts altogether, even peanut butter, which was just as well considering what was to come further on down the line. 

The problem is, if a baby has a food allergy, there is the possibility that there may be more lurking. I had been warned to be careful to introduce one thing at a time - even with spices. Each new food was to be given four or five days in a row, in case it took a while for an allergic reaction to develop. 

Concerned that Baby might not get enough calories, as she wasn't having cow's milk, the Dietitian advised adding an extra spoonful of oil to Baby's portion of food. To be honest, I didn't really follow that piece of advice, too much, because Baby has a healthy appetite and apart from her first month of life has never particularly looked like she was wasting away!

In fact, Baby has done so well that my only other concerns have been over the fairly limited diet that Baby preferred to stick to, for quite a while and the fact that she wasn't eating her five-a-day. For ages, Baby only seemed to like fried egg for breakfast and lunch - not a whole one (I hasten to add) we mostly stuck to the yolk, as that was the bit she liked! However, the Dietitian was able to run through Baby's diet with me, was happy that she was getting the right nutrients and told me not to worry too much about that famous five-a-day. Babies, it seems, need much less fibre than adults. 

Only fried egg would do!

Knowing that has made me able to relax and discover that Baby, (given time, and provided with good healthy options) is actually fairly instinctive about what she needs - if she majors on one food group at one meal, she usually stocks up on others later. When a cold is brewing, like me, she suddenly craves juice! So apart from the early stages, when food needed to be introduced carefully, we have tended to go with the flow. 

We've gone for more of a 'Baby-led Weaning' approach - we tend to prepare food for ourselves that we know is suitable for her (avoid sugar and salt, as well as dairy, if you do this) which means much less stress all round. The only problem is, anything that's ours, is now fair game for her. 'I'm very clever at sharing,' she said happily the other day... as she helped herself to my lunch!!!



Update! 

Eggs, it turns out are even more brilliant than I realised. Researchers have recently found that eggs contain twice as much Vitamin D as was previously thought! Meaning they contain two thirds Vitamin D daily requirements!! Great news, for those who can have it!

These more recent posts may be useful for anyone wondering which dairy free milk is best:

Which dairy free milk is best?

Finding the perfect formula for the Dairy Free Baby


Further Reading:

Neocate Weaning Guide
Neocate Food Allergy Cookbook
Weaning and up to One Year
Feeding Tips for Toddlers: from One Year (Nutramigen)
Cow's Milk Free Weaning Diet (Norfolk NHS)