Transcript Paediatrics Oct 97

®
Primary Course in Nutritional & Environmental Medicine
Paediatrics
Paediatrics
Nutritional Status of Children
Behaviour & Learning Disorders
Lead
Autism
Children in general nutritional
practice
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Pediatrics 2005;115;736-743
www.pediatrics.org/cgi/content/
full/115/3/736
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Pediatrics 2005;115;736-743
37 studies of dairy or unsupplemented
dietary Ca intake
 27 studies found no relationship between
dairy or dietary Ca intake and measures of
bone health
 Remaining 9 studies : the effect on bone
health are small
3 studies were confounded by Vit D intake from
fortified milk
6 found positive relationships in some measures but
not others
1 found an effect of increasing dietary Ca intake on
BMD when habitual Ca intake was < 400 mg/day
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Pediatrics 2005;115;736-743
Physical activity
 Primary modifiable stimulus for increased
bone growth
Calcium
 Intake, turnover, absorption and excretion
rates determine the availability of Ca for bone
growth and development
 Absorption is modulated by
food source
Form of Ca salt
Presence of phytates or oxalates
Vitamin D status
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Pediatrics 2005;115;736-743
Calcium
Urinary losses modified by
Potential renal acid load of the diet
Total dietary protein
Dietary sodium content
Dietary potassium content
Caffeine intake
Smoking
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Pediatrics 2005;115;736-743
Calcium supplements
9 of 10 RC trials ( 300-1000 mg daily )
1-6% increase in BMD
But effect is transient ( not more than 2
years )
Effect did not persist into late adolescence
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Pediatrics 2005;115;736-743
Adult reference
Weinsier RL, Krumdieck CL. Dairy foods
and bone health: examination of the
evidence. AmJClinNutr.2000;72:681-689
Metanalysis, 57 papers
…” body of evidence appears inadequate
to support recommendation for daily intake
of dairy foods to promote bone health in
the general US population”
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PEDIATRICS Vol. 107 No. 4 April 2001, p. e53
 Hypovitaminosis D in Healthy Schoolchildren
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Received Aug 2, 2000; accepted Nov 2, 2000.
Ghada El-Hajj Fuleihan*, Mona Nabulsi , Mahmoud Choucair*, Mariana Salamoun*, Carmen Hajj Shahine*, Aline Kizirian§, and Raja Tannous§
From the * Department of Internal Medicine, Endocrine Division, Calcium Metabolism and Osteoporosis Program; and the Departments of Pediatrics
and § Food Technology and Nutrition, American University of Beirut, Beirut, Lebanon.
Background. Vitamin D is essential for skeletal growth, but there are currently no guidelines for vitamin D supplementation after infancy. This study
investigates vitamin D insufficiency in healthy children.
Methods. Children ages 10 to 16 years from 3 private schools in Beirut, Lebanon, with differing socioeconomic status (SES) were studied: 169 in the
spring of 1999 and 177 in the following fall; 83 students participated in both study phases. They had a physical examination, answered a dietary
questionnaire, and blood was drawn for calciotropic hormones and indices of bone turnover.
Results. Overall, 52% of the students were vitamin D-insufficient; the proportion of insufficiency was 65% in the winter and 40% at the end of the
summer. During both seasons, girls had lower vitamin D levels than did boys; those who followed the dress code of covered head, arms, and legs
had the lowest levels. Students in the mid-SES school had lower 25-hydroxyvitamin D (25-OHD) levels than did the ones from the high-SES school.
After adjusting for confounders, gender, SES, and body mass index remained the significant predictors of vitamin D levels in both seasons
(R2 = 0.53, for spring and 0.28 for fall). There was a significant inverse correlation between 25-OHD levels and parathyroid hormone levels that was
best fitted by a curvilinear model (R2 = 0.19).
 Conclusion. Even in a sunny country, hypovitaminosis D is common in

schoolchildren, more so in the winter. Girls, especially those with a lower SES, are at
particular risk. The inverse changes in parathyroid hormone suggest that insufficient
vitamin D levels may deleteriously affect skeletal metabolism in healthy
adolescents. Vitamin D insufficiency may be prevalent in many other countries
where supplementation of milk with vitamin D is not mandatory. Our results call to a
reconsideration of vitamin D supplementation in high-risk adolescents to further
optimize skeletal health. vitamin D insufficiency, bone metabolism, nutrition, gender,
socioeconomic status. .
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Fruit And Vegetable Intake
 Study from the National Cancer Institute
Krebs-Smith et al.: Fruit and Vegetable Intake of
Children and Adolescents in the US: Arch Pediatr
Adolesc Med/Vol 150, Jan 1996
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Fruit And Vegetable Intake
“ Diets that are abundant in fruits and vegetables
are associated with a decreased risk of cancer
of the colon, breast, lung, oral cavity, larynx,
esophagus, stomach, bladder, cervix, and
pancreas”
“Childhood patterns are important determinants
of adult risk of certain diet-related cancers”
“The habit of eating lots of fruits and vegetables
beginning during childhood is a significant
positive predictor of fruit and vegetable intake
among adults”
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Fruit And Vegetable Intake
The study’s results were that
nearly 1/4 of all vegetables consumed
by children and adolescents were
french fries
intake of all fruits and dark green/or
deep yellow vegetables were very low
compared with recommendations
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Nutrition Intake
Prehistoric - Today
Dietl,H. Ohlenschlaeger,G
Handbuch der Orthomolekularen Medizin 94
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Prehi stor ic
Today
Protei n %
2 0 - 35
1 0 - 20
Carb ohy dra t es
%
Fat t %
4 0 - 50
4 0 - 50
20
40
poly / sat FA
1 .5
0 .4
Om e ga - 3 - FA
1 -1 .5 g
0 .1 -0 .2 g
Om - 6 / Om - 3
2 -4
10
Sugar g/ day
1 0 - 20
8 0 -1 0 0
Fru ct ose
5 -1 0
4 0 - 50
Chol mg / d
600
600
Vit amin C mg
400
80
Fib re g
45
20
Vit amins
high
low
So dium mg
700
3 00 0
Calciu m mg
1 50 0
700
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CV risk in children
Porkka KV, et al. The cardiovascular risk in young Finns
study. Atherosclerosis. 1994;105:63-69
Increased TFA’s increases risk for CV disease
Process starts in childhood
Changes in intima thickness and lumen
diameter, age 1 - 15
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Trans Fatty Acids
Decsi, et al. Ann Nutr Metab 39,36-41 (1995)
present in hydrogenated vegetable oils
4-6% was considered to be safe
but increase in LDL cholesterol
impairment of EFA metabolism
“LCP are essential for normal growth,
therefore inhibition of LCP synthesis in
childhood is of serious concern”
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Children and Nutrition
Pollitt E. Does breakfast make a difference in
school? J Am Diet Assoc. 1995;95:1134-1139
Nutritious breakfast may prevent nutrient
deficiencies
Omission of breakfast alters speed and
accuracy of information retrieval
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Children and Sugar
Wender EH, Solanto MV. Effects of sugar
on aggressive and inattentive behaviour
in children with ADD wit hyperactivity and
normal children. Pediatrics.
1991;88(5):960-966.
High sugar meal or placebo diet
more aggressive after sugar-richmeal
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Brain and Glucose
Energy for neuronal function
Neurotransmitter production and
secretion
Electro-physiological brain function
Simple COH have different effect on
neurochemistry than complex COH
 White JW, Wolraich M. Effect of sugar on
behaviour and mental performance.
Am J Clin Nutr. 1995;62(suppl):242-249
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Xenobiotics and Behaviour
well known lead studies
others
Manganese, Aluminium, Cadmium
Oxidation in CNS and dopamine depletion
Development of brain free radical
scavenging system and lipid peroxidation
under the influence of gestational and
lactational cadmium exposure.
Human Exp Toxicol. 1995;14:428-433
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Oils ain’t oils
Pediatric dietary lipid guidelines: a policy
analysis. J Am Col Nutr.1995;14(5):411-418
Total dietary fat not a problem
Type of fat
Increase in Omega 3 FA’s
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Brain and EFA’s
CNS and retina of eye are rich in
n-3-FA’s partic. in DHA
precursor alpha-linolenic acid
breast milk has high concentration
formulas very low
Macrides M, Neumann et al. Fatty acid
composition of brain, retina and erythrocytes in
breast- and formula-fed infants.
Am J Clin Nutr. 1994;60:189-194
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Brain and EFA’s
n-3 FA’s
ALA, EPA and DHA
brain and visual development
balance immune and inflammatory reactions
balance effect of linoleic acid
corn, safflower, sunflower, soy oils
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Essential Fatty Acids
 Overt
–
–
–
–
–
–
Signs of Deficiency
Dry Skin
Dry, lusterless, unmanageable or brittle hair
Dandruff
Dry, patchy skin
Brittle nails
excessive or firm cerumen
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EFA - Suspect Signs of Deficiency
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Cold Sensitivity
Allergies
Autoimmune Disease
Seborrhoeic Dermatitis
Psoriasis
Acne
Aging Spots or Vitiligo
Osteoarthritis
Arthralgias
Hypertension
Hyperlipidaemia
CV Disease
Endocrinopathies
Mental Disorders
Cancer
Diabetes
Alcohol Intolerance
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Vertigo
Migraine
Hiatal Hernia
Gastritis
Irritable Bowel
Peptic Ulcer
Diverticulosis
Ulcerative Colitis
Chronic Recurring Infections
Myalgias
Neuralgias
Tinnitus
PMS
Menopausal Symptoms
Bursitis
Glaucoma
– Prostatitis
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Behaviour, Learning
and Omega-3 FA’s
Stevens,Laura, et al.,
Physiology and Behavior, 1996;59(4-5):915-920
 96 boys, age 6-12
inverse relationship b/w Omega-3
FA’s concentration and
behaviour, learning and health
problems
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Nutrient deficiency in low fat diet
Nicklas TA, Webber LS, et al. Nutrient adequacy
of low fat diets for children.
Bogalusa Heart Study. Pediatrics.1992;89:221-228
B6 Pyridoxine
B12 Cyanocobalamin
E tocopheroal
B1 Thiamine
B2 Riboflavin
B3 Niacin
8%
34 %
32 %
18 %
20 %
23 %
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lower
lower
lower
lower
lower
lower
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Nutrient Intake and Fatness
Moore et al. Am J Epidemiol 139 (11) S56(1994)
131 children (Framingham Children Study)
Saturated Fats and Sucrose were
strongest predictors of body fatness for
girls
Total Fat and COH strongest for boys
 = nutrient composition more important
than total caloric intake
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Diet and IQ
Schoenthaler,S., Nature,July 25,1991;352:292
Discussion in Lancet
Double-blind placebo controlled
615 school children in 4 schools
RDA supplementation over 10 weeks
significant gain in non-verbal intelligence
803 schools = 1.1 Mio schoolschildren
Diet policies, only nutrient dense meals to be
served at school
16 % improvement in scholastic achievement
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Fruit Juice
Fruit Juice Consumption, Growth and Development
Nutrition Week, March 18, 1994;7
Study of 14-27 month old children with
20-30 ounces of juice = 25-60 % of daily
calories
When intake of fruit juice was reduced,
children had more caloric intake and
gained weight
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ADD
ATTENTION DEFICIT DISORDER
 1. HYPERACTIVITY
 ( ADD with hyperactivity )
 2. LEARNING DISABILITY
 (ADD without hyperactivity )
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ADD with Hyperactivity
 Signs of
 inattention
 impulsiveness
hyperactivity
 inappropriate for mental and
chronological age
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ADD with Hyperactivity
Main discussion point in NEM:
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food additives
food sensitivities
sugar
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ADD with Hyperactivity
 Incidence:
3 - 20 %
boys : girls = 9 : 1
 Onset :
~ 3 years
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ADD with Hyperactivity
 Characteristics:
 Hyperactivity
 Perceptual motor impairment
 General coordination deficit
 Emotional lability
 Disorders of attention
 Impulsiveness
 Disorders of memory and thinking
 Specific learning disability
 Disorders of speech and hearing
 Equivocal neurological signs and
 EEG irregularities
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Food Additives
 up to 5000 are used
13 - 15 gms per day consumption
 Feingold hypothesis:
 40 - 50 % of hyperactive children are
sensitive to
food colours, flavours, preservatives
and naturally occuring salicylates &
phenolic compounds
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Feingold - Connor
Type of placebo
cookie
- chocolate
 other studies show
33 - 59 % reactions to chocolate
 Inadaequacy of challenge dose
 study dose = 13 mg
compared to 150 mg (FDA data)
 other studies ( 75, 100 and 150 mg ) =
significant impairment of learning performance
in 85 % of tested children
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Feingold - Connor
Supportive studies in AUS
 Rowe et al : Artificial food colourings and hyperkinesis
Aust Paediatrics J 15:202, 1979
 Rowe: Food additives.
Aust Paediatrics J 20:171-4, 1984
 Cook,P: The Feingold dietary treatment of thehyperkinetic
syndrome. Med J Austr 2:85-90, 1976
 Salzmann: Allergy testing, psychological assessment and
dietary treatment of the hyperkinetic child syndrome
Med J Austr 2:248-251, 1976
 Weiss et al : Behavioural response to artificial food colours
Science 207:1487-9, 1980
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Food Sensitivities
Common:
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Cow’s milk
Peanuts
Wheat
Orange
Chocolate
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

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Corn
Yeast
Soy
Tomatoes
Grapes
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Food Sensitivities
Testing
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Elimination-challenge
IgE
IgG 4
Electro-dermal
Kinesiology
Cytotoxic
Alcat
Intestinal Permeability
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ADD and EFA’s
Stevens et al. Am J Clin Nutr 62 (4), 761-768 (1995)
53 boys with ADHD, 43 controls
significantly lower conc. of EFA’s
many symptoms of EFA deficiency
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Learning Disability
ADD - without hyperactivity
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Learning Disability
NUTRIENT DEFICIENCY
any nutrient deficiency can result in
impaired CNS function
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Iron Deficiency
Webb,TE. J.Spec.Education 1974
Pollet, AJClinNutr 1986
Behaviour, Learning Disability
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Learning Disabilities
HEAVY METALS
particularly lead
many studies. Lancet 1972 - until today
Recent studies in Sydney and NSW
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Learning Disability
BEHAVIOURAL
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OPTOMETRIST
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ADD and Literature
Weiss,G. NEJM, Nov 15,1990;323(20):1413-1414
“Hyperactivity in Childhood”
Editorial review regarding Zametkin’s article.
Study supports view of metabolic
dysfunction, but probably not single cause
Others are lead exposure, poverty and
stressful family
Stimulants have been used with some
success, but their widespread use and long
term efficiency is questionned.
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ADD and Lead
“ Lead Toxicity May Underlie Behavioral, Learning
Disorder”,Family Practice News,
Dec.15-31,1991;21(24):37.
D. Herbert Needleman,
Annual Meeting of the American Academy
of Child and Adolescent Psychiatry:
“Any child with behavioral disorder or
learning disability should be tested for
lead exposure immediately..”
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Lead
CDC in 1991 reduced action level
for lead poisoning from
25 ug/dl (set in 1975 ) to 10 ug/dl
Report: Preventing Lead Poisoning in
Your Children.
Office of Public Affairs, CDC, Atlanta,
Georgia 30333
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Lead
Beck, Barbara, Fundamental and Applied
Toxicology,1992;18:1-16
“Symposium Overview: An Update on Exposure
and Effects of Lead”
 Neurobehavioral effects
 Carcinogenicity
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More on Lead
Journal of th American College of Nutrition,
Oct1992;11(5):608/37
“Overview of Lead Toxicity Early in Life, Effects on
Intellect loss, Hypertension.
10% of all children have been exposed to
unsafe levels of lead
10-50% of children have increased lead levels
In 1978 lead levels in babies’ teeth were
correlated wit neurobehavioral function,
inversely related to lead dentine levels
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Lead cont’d - JACN Oct 1992
11 years later significant association with
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

lower class standing
absenteeism
lower verbal scores
poor coordination
longer reaction times
Epidemiological and clinical studies:
 hypertension, kidney dysfunction
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Lead - Intelligence
Tong, Shilu, et al (Uni of New England,Armidale)
BMJ,1996;312:1569-75
375 children born close to a lead smelter
IQ inversely associated with antenatal
and postnatal blood lead concentration
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Lead Poisoning and Zinc
Could Zinc help Protect Children from Lead Poisoning?
Schmitt, Nicholas, Canadian Medical Association Journal,
January 1, 1996;154(1):13-14.
 High intake of lead results in neurological
damage
 Zinc is a known metabolic antagonist of lead
 Zinc supplementation may be of benefit in
children with risk of lead poisoning
 Children from low income family are deficient
in Zinc
 Address Zinc deficiency and reduce lead
exposure
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Lead and Vitamin C
Dawson,E.et al, J of the Am Coll of Nut
1997;16(5):480/Abstract 42
75 adult males 20-35 years
0, 200, 1000 mg Vit C for 1 months
mean blood lead levels
Results
no change in 0 or 200 mg Vit C
in 1000 mg group
reduction from 38 to 8 ug/dl in 1 week
remained for the length of the study
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Lead levels and Behaviour
Needleman et al. JAMA 275(5), 363-369 (1995)
850 primary school aged boys
follow up over 4 years
lead exposure associated with
 sleep disturbances
 attention problems
 aggression
 delinquency
 anxiety/depression
 social problems
negative effects of lead follow a developmental curve
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AUTISM
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AUTISM
 Syndrome of early childhood
 male : female = 4 : 1
 Profound failure to develop social
relationships
 Language disorder with
 impaired understanding
 echolalia,pronominal reversal
 Rituals and compulsive phenomena
 General retardation in intellectual
development ( most cases )
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AUTISM
Organic defect in brain development
as a result of
abnormal SEROTONIN metabolism
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AUTISM
Prognosis:
 generally poor
 related to results of IQ testing
 in children < 50, temporal lobe epilepsy
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AUTISM
Abnormal serotonin metabolites are
seen in autistic children
 may significantly contribute to their
mental dysfunction
LSD and other hallucinogens are
serotonin analogues
Serotonin and its metabolites are
produced in and absorbed from
intestines ( ? leaky gut syndrome )
Recent study on secretin
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Autism
Amino Acid Metabolism
Fatty Acid Metabolism
Opiods from casein and gluten
Other toxic metabolites
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AUTISM and Rx
RECOMMENDATIONS ARE INCOMPLETE
Specialised services and counselling
Eliminate factors that play a role in
aggrevating
CNS dysfunction ( eg. food sensitivities )
Milk, wheat, sugar = 40 - 50 %
improvement
Amino acid and Fatty Acid assessment
Bowel detox
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AUTISM and Rx
Suggested supplementation
 Ascorbate
B6
 Folic acid
 B 12
 Mg
Omega 3 and 6
1g
50 mg
500 mcg
500 mcg
100 mg
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Milk and Tonsillitis
Hodson,A., The Journal of The Royal Society of
Medicine, Jan 1991;84:58
Milk allergy may be an etiological factor in tonsillitis
Few children in countries without milk
have ever tonsillitis
If substitution of milk powder in those
countries, significant increase in
tonsillitis eg. WHO in Lybia
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Acute Otitis Media & Antibiotics
Browning,G., BMJ April 14,1990;300:1005-1006
Review: Childhood Otalgia:Acute Otitis Media;
Antibiotics Not Necessary in Most Cases
Child with ear pain - less than 50%
chance of acute OM
After initial myringotomy - 20-30 % no
pus, no bacteria
No consistent data supporting antibiotic
use in serous OM
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OM & Antibiotics
(Browning)
85 %of children pain free after 24 hours
irrespective of Antibiotics
Evidence that AB’s reduce incidence of
mastoiditis is negligible
Recommendation:
Antibiotics only if otalgia persists for
longer than 24 hours
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OM & Antibiotics
(Browning)
If policy were instituted in UK:
1.84 Mio fewer prescriptions for antibiotics
Saving of 6 Mio pounds per year
In Scandinavian countries antibiotics are not
routinely given and parents do not expect
them
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Otitis Media
Food Allergies Can Trigger Ear Infection
Pediatric News, 1991;25(2)
78 % of children with chronic ear infection
were sensitive to different foods incl
 milk, wheat, peanuts, corn
Elimination for 11 weeks - resolution in 88 %
Reintroduction of those foods - 66 % relapse
Suggested mechanism : Production of
mucous and swelling of Eustachian tubes
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Eustachian Tube Dysfunction
Derebery,M et al., Am J of Otology,1997;18:160-165
underlying inhalant and food allergy
most pt’s have at least 1 positive reaction
to food by provocation or skin testing
most have symptom improvement with
dietary elimination
 wheat
 milk
 corn
 egg
 yeast
 soy
70.7 %
51.5 %
60.9 %
51.7 %
55.9 %
45.5 %
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Milk allergy and Soy
J of Pediatrics 1999; 134:614-22
14 % of IgE cow’s milk allergic
children have IgE allergy to soy
“safe to introduce under medical
supervision”
“Soy remains unsuitable for children
with non-IgE-associated cow’s milk
allergy involving enterocolitis in
these non-atopic patients”
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Vitamin C & Antibiotics
“Vitamin C Enhances Antibiotic Therapy”
The Nutrition Report,April 1992;10(4):31
Staph aureus strains lost resistance in 4/6
strains after 6 hours
Antibiotic levels effectivity increase
by 50-75% after Vit C exposure
23-93% Vitamin C was bacteriocidal
© 2005 ACNEM & Joachim Fluhrer
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Vit C & Antibiotics
cont’d
Vitamin C may modify bacteria DNA
Vitamin C shows no mutagenic or
carcinogenic effects on normal cells
Vitamin C inhibits bacterial resistance to
Ab therapy
© 2005 ACNEM & Joachim Fluhrer
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Milk & Intestinal Permeability
Cows’ Milk Allergy, Sugar and Intestinal
Permeability
Troncone,R., Allergy 1994;49:142-146
90% of infants who developed symptoms
after challenge
showed increase post-challenge
intestinal permeability
4.5 % in non-reactors
© 2005 ACNEM & Joachim Fluhrer
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Food Allergy and Atopic Disease
Annals of Allergy December 1993, 71:495-502
less than 20 % are true allergy or hypersensitivity
food ‘allergy’ in at least 25 % of infants with
atopic eczema
intestinal permeability may increase risk of food
allergy
breast milk may reduce atopy
“research should move beyond the obsession
with IgE mediated type 1 reaction
© 2005 ACNEM & Joachim Fluhrer
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J Pediatr. 2004 Nov;145(5):606-11.
Lymphoid nodular hyperplasia and cow's milk hypersensitivity in children with chronic
constipation.
Turunen S, Karttunen TJ, Kokkonen J.
Department of Pediatrics, University Hospital Oulu, Finland.
OBJECTIVE: To investigate the incidence of cow's milk allergy as evidenced by milk
challenge and the findings of endoscopic and immunohistochemical examinations in
children with chronic and refractory constipation. STUDY DESIGN: Thirty-five study
subjects (mean age, 8.3 +/- 3.3 years; range, 3-15 years; 17 girls) and 15 control
subjects (mean age, 11.7 +/- 3.2 years; range, 2-15 years; 9 girls) were studied by
colonoscopy and a 4-week cow's milk elimination and challenge. RESULTS: Lymphoid
nodular hyperplasia was the most prominent endoscopic finding in half of the subjects
(46%), mostly occurring patchily in the transverse colon. Histologic findings other than
lymphoid accumulation and mildly increased density of eosinophils were few. During the
milk elimination and with supportive medication, 83% of subjects remitted. Constipation
and/or other gastrointestinal or skin symptoms relapsed only in one third (34%) during
the cow's milk challenge, these having significantly higher densities of intraepithelial
gammadelta + T cells ( P <.001) in the biopsy samples of the terminal ileum as
compared with the control subjects. CONCLUSIONS: We were able to find formal
evidence for the presence of cow's milk allergy in children with chronic constipation.
97
© 2005 ACNEM & Joachim Fluhrer
Breast Feeding and Atopic
Disease
Saarinen,Kajosaari:Breastfeeding as
prophylaxis against atopic
disease:Prospective follow-up study until
17 years old.
Lancet1995; 346:1065-69
“Breast feeding is prophylactic”
© 2005 ACNEM & Joachim Fluhrer
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Group
Breast Feeding and Atopic
Disease
Age
1
3
5
10
17
age 17
<1 month or no
23
36
46
43
65
54
1-6 months
23
24
27
31
36
23
>6 months
11
22
34
29
42
8
substantial atopy
CLINICAL HISTORY, SKIN-PRICK TEST,IGE, RAST, NASAL EOSINOPHILS
© 2005 ACNEM & Joachim Fluhrer
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Infantile Colic - Allergy?
 Hill et al.Royal Children’s Hospital, Melbourne:
 A low allergen diet is a significant intervention in infantile
colic: Results of a community-based study.
J Allergy Clin Immunol;96,6 Part 1
 DBRPC trial ofcolicky infants over 1 week
 38 bottle fed and 77 breast fed
 casein hydrolysate or cow’s milk
 Mothers diet: oligo-antigenic diet
 free of additives, preservatives colours
 free of milk, egg, wheat and nuts
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Infantile Colic - Allergy?
“Significant higher rate of improvement
39% compared to 16%
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