Complementary Feeding in Infants With CMPA

As infants grow and develop, their needs for energy and nutrients start to exceed what is provided by breastmilk or hypoallergenic formula, and this is when complementary feeding (CF) should start.

The WHO and other experts suggest, complementary feeding (CF) is the process of starting other foods and liquids when breastmilk alone is no longer sufficient to meet the nutritional requirements of infants.^1-4 The WHO recommend exclusive breastfeeding for 6 months, followed by the introduction of CF alongside breastfeeding.¹

Complementary foods are considered necessary for both nutritional and developmental reasons, and are an important step in the transition from milk feeding only, to the addition of family foods.4 Furthermore, an energy gap develops, usually beyond 6 months of age, which needs to be covered by complementary foods. In infants with an established food allergy such as cow’s milk protein allergy a replacement hypoallergenic formula also supports the ‘’energy gap’’. This is represented in Figure 1., showing the energy provided by breastmilk and when the energy gap starts to develop.

Energy Provision From Breastmilk and the Energy Gap

In infants with CMPA, there is no evidence that delaying the introduction of other potentially allergenic foods (e.g., wheat, soya, egg, fish, nuts) will prevent the development of additional food allergies. In fact, evidence is building that early, rather than delayed, introduction to these foods could be beneficial.⁶

In infants with established CMPA, CF should therefore begin as for an infant without a food allergy (around 4-6 months but not before 4 months). It has been suggested, for example, in the UK guidance that “These children may benefit from the earlier introduction of cooked egg and then peanut alongside other solids, from around 4 months of age” but not before 4 months.⁷ While some experts suggest that other allergens should be introduced one at a time.⁸

Infants with CMPA have a higher risk of nutrient deficits due to dietary exclusions, for example, breastfed babies on a maternal exclusion were at risk of B12 deficiency, while initiation of CF was associated with a better B12 status.⁹ In addition, vitamins E and D^9-11, calcium¹¹, iron⁹ and iodine¹² were commonly deficient in infants with CMPA. Supplying these nutrients in a ‘’safe’’ format such as in allergen-free enriched baby cereals, and/or hypoallergenic formula, is considered beneficial.¹²

NB. Infants with CMPA should always be referred to an allergy specialist for advice.¹³

Which Foods and Food Groups Should Be Introduced?

Small amounts of different food groups e.g., vegetables, fruits, starchy foods, protein sources without added salt or sugar should be included7 – (see table for some examples).

Food Groups	Nutrients Provided	Examples
Local Staple Carbohydrate	Energy	Cereals (rice, maize, wheat), cassava, sweet potato, for babies with CMPA foods should be dairy protein free!
Foods from animal origin or vegetarians/vegan options*	Protein, energy, iron, zinc	Red meat, chicken, fish, eggs, beans, peas, lentils, nuts (ground and tree), seeds
Dairy, or dairy replacement when CMPA	Protein, energy, vitamins, minerals	Dairy products, fortified cereals, or non-dairy options and replacement hypoallergenic formula when CMPA
Fruits and vegetables	Carotenes, folate, vitamin C, some minerals and trace elements	Carrots, butternut, papaya, spinach, broccoli (not limited to these)
Fats & oils	Energy, essential fatty acids, fat soluble vitamins	Vegetable and seed oils, margarine, butter, dairy free spreads when CMPA

Adapted from WHO, 2009^*

Common allergy causing foods can be introduced one at a time. This is because infants with CMPA have a 50% higher risk of developing other allergies.⁸ This also makes it easier to identify a problem food if an allergic reaction does occur. Once introduced and tolerated, these foods should be regularly included the infants’ diet.⁸

For example, in the UK they suggested eczema should be well-controlled before introducing allergens into the diet i.e., cleared prior to introducing allergenic foods (to help detect if tolerant).⁷

The more diverse the diet the better. An increase in the diversity of the diet was associated with better growth indices in young children14-15 and may be associated with reduced allergic outcomes.¹⁵

A variety of different foods and flavors should be introduced while avoiding cow’s milk/dairy proteins. During the introduction of foods, breastmilk or hypoallergenic formula will contribute a major part of the nutrients needed by the infant and can also be used in recipes.

Importance of Reading Product Labels

Since 2005 the European Union has 12 foods, including dairy/milk, that are required to be presented as content on the label of all processed or prepackaged foods.¹⁶

Similar legislation exists in the US, where the Food Allergen Labelling and Consumer Protection Act proposed that all milk products require an ingredient statement.

Dietetic intervention commonly includes teaching families how to read food labels, to help mitigate risk of cross contamination.¹⁷ This will include informing parents/caregivers to check food labels thoroughly every time they shop – even if they have bought a product before, as recipes sometimes change.¹⁸

Frequent Questions About Complementary Feeding

Are infants and children with CMPA at a greater risk of developing feeding issues?: Yes, behavioral feeding issues are more common in infants and young children with a diagnosis of CMPA due to fear of a repeated reaction (especially when severe CMPA).¹⁹
Should Complementary Feeding stop if the child is ill?: During illness HCP commonly encourage that the child is given his/her favorite foods as well as small frequent meals, but CF should not be stopped. Furthermore, during illness encourage extra fluids, including more frequent breastfeeds or hypoallergenic formula (when formula-fed).⁵
Do children with CMPA need additional vitamins and minerals?: Infants and children with CMPA, especially those with gastrointestinal issues, appear to be at a higher risk of deficits when not consuming a hypoallergenic formula.²⁰ While unfortified complementary foods that are 100% plant-based may not provide sufficient amounts of certain key nutrients (eg. iron, zinc, vitamin B6 and calcium).^2,5 Use of fortified cereals can boost the intake of these nutrients, which is especially important in those following vegetarian and vegan diets.
Any specific needs for infants/children following a vegan or vegetarian diet?: Infants and children with CMPA who are not breastfed should receive a replacement hypoallergenic formula, which is nutritionally complete. Vegan diets require dietetic supervision - and for those following a vegan or vegetarian diet, careful attention should be paid to the adequacy of vitamins B12 and vitamin D, iron, zinc, folate, omega-3 fatty acids (especially DHA), protein and calcium, and ensure adequate energy in provided.^4,21