Professional profile elsie Widdowson - a pioneer in dietetics 10 Professional profile elsie Widdowson - a pioneer in dietetics

ursula arens Writer; nutrition & dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the british Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews

dr margaret ashwell, obe, phd, fafn, rnutr (public Health), research fellow

Dr Margaret ashwell has been a Senior research Scientist with the Medical research council, Science Director of the bNF and an Independent consultant, working for government and industry. She is an author and editor of the biography of the nutrition pioneers, Mccance and Widdowson. She was appointed an Obe in 1995 and was elected as a Fellow of the association for Nutrition (afN) in 2012.

the imPortAnCe of tender loving CAre: elSie WiddoWSon’S reSeArCh in germAny

dr elsie Widdowson (1906-2000) was an extraordinary pioneer dietitian and the fact that the Bda annual lecture bears her name is just one of the many ways that her achievements continue to be recognised. a tribute to her and professor robert mccance was edited by one of the authors (ma) and published by the British Nutrition foundation in 1993. their joint professional timeline spanned 60 years, but some of their most fascinating research adventures occurred during their time in bleak, post-war germany.

In 1946, the Medical Research Council suggested that funding was given to Robert McCance and Elsie Widdowson to examine how war and extreme food shortages had affected the German civilian population. They toured many cities and found that the hospital in Wuppertal had the best laboratory facilities, but especially of interest, was the presence of a completely bilingual English-German doctor who was anxious to support their research. What had started as a six-month project stretched into three years of data collection.

One of the projects that Elsie led, was an examination of the effects of different kinds of bread on growth. This was specifically to support decisions on post-war bread specifications, for although the war time national loaf made from high extraction flour was healthy, it was unpopular. In January 1947, Elsie found a suitable orphanage in Duisburg for the bread feeding experiments. The children were all underweight and under height and for 18 months they were fed five different diets where 75 percent of energy was provided by bread. The breads were made from one of five types of flour: 100 percent (wholemeal), 85 percent and 72 percent extraction (white) and two white flours enriched with B vitamins and iron by a smaller or greater amount. In addition, all flours were fortified with calcium carbonate. Conclusions were that all of the breads were equal in relation to supporting growth in the children. Elsie announced her results at the annual conference of the British Medical Association and, in a time before PowerPoint, presented five of the girls, one from each of the different bread groups, and challenged the learned audience to detect any differences (there were none). Perhaps not the most scientific way to document the effects on growth of different diets, but a very exciting adventure for some young German orphans and a very interesting visual aid for the learned medics.

Another project that Elsie led was an examination of the effects of providing additional bread to the meagre baseline diets of young children. In 1948, Elsie recruited two small municipal orphanages which each housed about 50 children between the ages of four and 14 (the average age was just under nine). The children were all short and thin and would be weighed every fortnight for a year. For the first half year, all children would be on the normal official rations and for the second half year, children at one of the orphanages would be given unlimited amounts of additional bread to fully satisfy their appetites, along with some extra margarine/jam and concentrated orange juice.

The results observed in the first six months were peculiar. Although all the children appeared to consume the same diet, changes in weight and height were different. At one of the homes, children gained exactly the predicted average amount of 1.4kg weight. In contrast, children in the other home gained on average less than 0.5kg.

The results in the next six months were even more peculiar. In complete contradiction to prediction, weights and heights of the children kept on standard meagre rations increased significantly. Children given the extra bread rations grew at only modest levels and, astonishingly, after the six month period, their average weights and heights were below those of the children in the orphanage not receiving supplementary foods. The observations were completely bizarre because weights had been so systematically collected, the food intakes so carefully measured and observed. The results seemed absurd and Elsie was mystified.

Elsie was busy, but always had time to care for the little things that needed thought and attention. Lois Thrussell was a research nurse tasked with doing all the measurements for the energy and mineral balance studies. But Lois was unhappy about the fact that she had been commanded out of a room in the orphanage; she had to do her research in a hen house. The issue of concern was that the hen house had whitewash on the walls, but it was prone to flake off and ruin the calcium balance measurements. Elsie was the Miss Fix-it, and found an expensive piece of cretonne to drape over the walls. But Lois was still full of tears and told Elsie of her anxieties over the way that the orphans were treated by the very harsh and vindictive housemother. Mealtimes were dreaded by the children, because this was the time in their day for public scorn and rebuke over trivial misdemeanours.

Elsie went to investigate and was able to confirm the constant fear of the children over public and victimizing reprimand by the housemother at mealtimes. Food would be cold and children would be in tears. Further examination led Elsie to find out the amazing coincidence that the ‘dragon-lady’ had transferred from one of the orphanages to the other (the one being given the additional bread) at exactly the six-month changeover period of the project. During the dragon-lady’s reign at the first orphanage, the children gained nearly one kilo less than at the second orphanage, despite identical food rations. During her reign at the second orphanage, growth in the children decelerated to the point that weights were below those of children not receiving the additional bread and juice. Elsie further discovered that the dragon-lady had a few particular favourites; children who could do no wrong in her eyes were always given praise. When she transferred between orphanages, she was able to transfer eight of these children with her; in the year of the project, the favourite children gained on average four kilos: one kilo more than any of the other children.

Elsie concluded from her study that psychological stresses due to harsh and unsympathetic handling could seriously curtail growth rates, maybe through influences on digestion. Of course, it would be impossible to repeat or confirm the research. But in poetic form, she included in her 1951 Lancet paper, the biblical reference from Proverbs that, ‘Better is a dinner of herbs where love is, than a stalled (fattened) ox and hatred therewith’.

More than 20 years ago, one of the authors (MA) was able to get Elsie to pull together her thoughts on research into a very short list of golden nuggets of advice, and many of the items reflect outcomes from her projects in Germany. This guidance, resulting from 60 years of research into nutrition science, is still valuable to dietitians and other researchers today and is the essential share-it item.

advice to a young scientist - by elsie Widdowson

• Treasure your exception - Your extreme results may be the most interesting part of your study. • Vary your conditions - Sometimes changing two variables give you results that changing single variables will not detect. • Do not be afraid of owning up to a mistake, even if your results have already been published - it is better that you publish a correction than giving someone else the pleasure. • If you’re using an animal as a model for human adults or children, be careful to choose an appropriate species of the right age for your experiments - Some observations are age or species specific. • If your results don’t make physiological sense, think! your may have made a mistake or your may have made a discovery - Check everything, but then think of alternative explanations - sometimes they are the new discovery. as shown above in the german orphanage study, tender loving care of children may make all the difference to growth and health.

Information sources • Ashwell M (ed) McCance & Widdowson; a scientific partnership of 60 years. british Nutrition Foundation, 1993 • Buklijas T. Food, growth and time: Elsie Widdowsons’s and Robert

McCance’s research into prenatal and early postnatal growth.

Studies in History and Philosophy of biological and biomedical

Sciences (2013) • Widdowson EM (1951) Special Articles: Mental Contentment and

Physical Growth. Lancet, 1951, i: 1316-1318

Juliana Scapin paediatric dietitian, Central London Community Healthcare nHS trust

Juliana is a registered dietitian for over 10 years and has experience mainly in paediatric dietetics in brazil and in the uk. her interests are in food allergies, nutrition products and appropriate prescribing.

CoWS’ milk Allergy SPeCiAliSt formulAe: APProPriAte PreSCribing. WhAt do We need to knoW?

food allergy is a recognised healthcare problem, with cows’ milk protein being the most common food causing allergy symptoms in infants and young children (1). it is established that the management of cows’ milk protein allergy (cmpa) following the diagnosis is complete or individualised avoidance of cows’ milk protein alongside the usage of suitable substitute milks.

Breast milk is suitable for the majority of infants suffering from CMPA, and mothers normally do not need dietary restrictions unless their infant presents symptoms whilst being breastfed (2). However, when breast milk is not available, advice on a suitable milk alternative is needed.

Cows’ milk allergy specialist formulae spend has been increasing significantly in the past years (3). It has been reported that the NHS spends £23.6 million per year on paediatric cows’ milk protein allergy management (4). It is estimated that the NHS cost of managing an infant suffering from CMPA with extensively hydrolysed formula (EHF) over a period of one year would be £1,853 and with amino acid formula (AAF) this would be £3,161 (5). Considering the NHS current financial situation, inappropriate spending has to be avoided (6).

Adding to future savings, the NHS aims to improve the quality of patients’ care (6), and it is known that appropriate prescribing can improve patient outcomes and safety (7). Therefore, it is essential to ensure that cows’ milk allergy specialist formulae are correctly and timely prescribed and reviewed.

reaSonS tHe Spend on CoWS’ miLk aLLergy formuLae iS riSing Cows’ milk allergy specialist formulae expenditure is progressively increasing in London over the years and is significantly higher compared with other specialist paediatric nutritional products.

figure 1

The following factors are believed to have been contributing to this (7): • increasing research in allergy, which leads to increased awareness of CMPA; • rising cost of products; • AAF being used inappropriately as first line, by some; • inappropriate initiation and/or prolonged usage of products caused by: - disparity in HCP knowledge about CMPA management and products; - poor communication to GPs, e.g. incomplete correspondence from HCPs recommending cow’s milk allergy specialist formulae in regards indicators for changing/stopping/reducing formula; + volume of prescriptions (number of tins per month); - GPs not acting as correspondence’s advice from specialists; - patients not reviewed by a paediatric dietitian as inequality in paediatric dietetic service provision.

CHooSing an appropriate CoWS’ miLk protein aLternative miLk The NICE guideline (8) recommends that a HCP with the appropriate competencies takes an allergy-focus clinical history in order to find/exclude a food allergy diagnose, which may lead to a formula initiation. This guideline also advises that a dietitian should be involved in the care of children suffering from food allergies and, therefore, in monitoring/advising the type, quantity and length of cows’ milk allergy specialist formula usage in combination with breast milk or as a replacement when breast milk is not available, as well as an appropriate diet. The following cows’ milk allergy specialist formulae options are currently available in the UK (9):

table 1: eHf options available in the uk

eHf manufacturer Suitable ages average cost per unit cost per 100kcal protein source (2) lactose content

Similac alimentum (400g) Nutramigen lipil 1 (400g) Nutramigen lipil 2 (400g)

abbott from birth £9.10 £0.43 Hydrolysed casein 95% peptides <1,000 da mead Johnson mead Johnson birth to 6 months £10.87 £0.54

from 6 months £10.87 £0.58

Hydrolysed casein 95% peptides <1,000 da

althera (450g) Sma

from birth to 3years aptamil pepti 1 (400g/800g) milupa birth to 6 months aptamil pepti 2 (400g/800g) milupa from 6 months £10.68 £0.47

£9.54/ £19.08 £0.49 £9.10/ £18.20 £0.47/ £0.43

Hydrolysed whey 99.3% peptides<1,000 da

Hydrolysed whey 73% peptides <1,000 da

cow & gate p Junior (450g) epti- Cow & gate from birth £12.58 £0.56 Hydrolysed whey 57% peptides <1,000 da Lactose free

Lactose free

Contains lactose

Contain lactose

Contains residual lactose

pregestimil lipil (400g)

infatrini peptisorb (200ml) – High energy formula

mead Johnson

nutricia

from birth £12.06 £0.60 Hydrolysed casein 95% peptides <1,000 da from birth to 18 months or 9.0kg weight £3.41 £1.71 Hydrolysed whey 73% peptides <1,000 da Lactose free

Contains residual lactose

Extensively Hydrolysed formulae (EHF)

About 90 percent of children suffering from IgE mediated CMPA (10) and 70 percent presenting non-IgE mediated CMPA (11) will achieve symptoms resolution with an EHF. Although the majority of infants will tolerate all EHF types, it is important to note that some with more severe presentations of CMPA may not and therefore need an AAF. Also the presence of lactose will improve the palatability of the EHF (2).

Amino Acid formulae (AAF)

Option for severe CMPA allergic symptoms when exclusively breastfed, severe forms of non-IgEmediated CMPA (e.g. eosinophilic eosophagitis), CMPA combined with faltering growth, reacting to EHF (2). Choosing an AAF when not indicated increases the cost burden on managing CMPA and may affect development of tolerance (albeit the data is very preliminary at this time) (13).

table 2: aaf options available in the uk

aaf

alfamino (400g) manufacturer Suitable ages average cost per unit

cost per 100kcal

Sma from birth £23.00 £1.14

Nutramigen puramino (400g)

mead Johnson from birth £26.80 £1.34

Neocate lcp (400g) nutricia from birth £28.30 £1.46 Neocate active (15x63g sachet) nutricia from 1 year £66.60 £1.48 Neocate advance (15x50g & 10x100g sachet) nutricia from 1 year £46.35/15x50g £58.60/10x100g £1.55 £1.47

Neocate Spoon (15x 37g sachet)

nutricia from 6 months £39.30 £1.45

protein source (2)

amino acids

Neocate Active/Advance are high energy formulae and should NOT automatically replace Neocate LCP. Neocate Spoon is a weaning food that may be used in some cases of multiple food allergies combined with faltering growth under a paediatric dietitian’s close supervision.

Soya formulae (SF)

Not suitable for infants <6 months of age due to phytoestrogens and should be used with caution in CMPA as risk of combined soya allergy (2). Can be purchased by patients over the counter.

table 3: Sf options available in the uk

Sf manufacturer Suitable ages

Wysoy (430g/860g)

Sma from 6 months

average cost per unit

£5.65 £11.00

Please note: Infasoy (Cow & Gate) has been discontinued since April 2015.

cost per 100kcal

£0.26 £0.25

protein source (2) Whole soya

Lactose free and Anti-Reflux formulae

Not suitable to be used in CMPA as they contain the whole cows’ milk protein. Can be purchased by patients over the counter..

Partially hydrolysed formulae

Not suitable for CMPA treatment (2).

Over the counter milk alternatives

such as soya, oats, coconut or other milk alternative enriched with calcium. May be used for children over one year of age reviewed closely by a paediatric dietitian if dietary intake and growth are adequate. Please note that rice milk is not suitable for children under 4.5 years of age due to its arsenic content (2).

age

less than 6 months approximate number of tins per 28 days 400g tin 450g tin 800g tin

10-13 9-12 5-7

6-12 months greater than 12 months

7-10

7 6-9

7 3-5

3-4

Restricting initial prescriptions for new patients to 1-2 tins will reduce wastage should the baby refuse to take the feed. Alternatively consider referral to a paediatric dietitian for assessment prior to prescribing or setting a repeat prescription

SuggeStionS to improve appropriate preSCribing praCtiCe Understand local spend data and then create initiatives to target local issues.

With local acute and community agreement produce local guidelines on infant formula

prescribing aiming to educate local GPs and other HCPs on the appropriate options to prescribe, as well as the appropriate quantities and length of usage, as well as when and where to refer for specialist review.

Increase awareness of cows’ milk allergy specialist formulae range and prices in HCPs that may be initiating a prescription; updates can be accessed on the London Procurement Partnership (LPP) website (www.lpp.nhs.uk). • Review prescriptions needs - review patients regularly advising on the most appropriate options. Consider over-the-counter milk alternatives enriched with calcium for patients over one year of age when under the close guidance of a dietitian as deficit in energy, protein, riboflavin, vitamin A and D and fatty acids are likely without adequate dietary sources (2). • Good communication - ensure correspondences to GPs are complete and clear in regards the formula prescription request to prevent unnecessary prolonged/excessive usage. Inform GPs that soya formula can be purchased by patients.

• Be aware of the MAP and BSACI guidelines

providing clear information on the diagnosis and management of CMPA.

Improve your own prescribing practice:

• Ensure best practice based on CMPA current guidelines to prevent CMPA misdiagnosis and, therefore, inappropriate usage of the specialist formulae, e.g. encourage regular formula reintroduction after period of cows’ milk protein exclusion to confirm diagnosis of CMPA (8).

CoWS’ miLk aLLergy SpeCiaLiSt formuLae appropriate preSCribing in a nutSHeLL The cost of cows’ milk allergy specialist formulae to the NHS is progressively increasing, and considering the NHS current financial situation, appropriate prescribing of these is paramount. Advising the right product for the right patient for

table 5

cows’ milk allergy specialist formula prescription template request

product name manufacturer unit size dose per day

Quantity per 28 days (no. of tins/bottles) goal of nutrition prescription prescription review plan this patient will be reviewed in << >> months by the Community dietetic team. Ensure GPs are informed when the prescriptions should be changed/reduced/stopped, as well as when the prescriptions should be reviewed by them, in case patients are discharged on prescriptions from your caseload.

Advising the right product for the right patient for the right length of time will not only save money, but can enhance patients’ clinical outcomes and safety.

the right length of time will not only save money, but can enhance patients’ clinical outcomes and safety. Dietitians having the expertise in this area can make a big difference by adopting initiatives to ensure cow’s milk allergy specialist formulae appropriate prescribing.

references 1 Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S et al. Diagnostic approach and management of cows’ milk protein allergy in infants and children:

ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr 2012, 55(2): 221-229 2 Luyt et al. BSACI guideline for the diagnosis and management of cows’ milk allergy. Clinical & Experimental Allergy 2014; 44, 642-672 3 London Procurement Partnership. report into paediatric nutritional products prescribing practices (online). www.lpp.nhs.uk/media/18287/Paediatric-Nutritional-

Products-Prescribing-Practices-in-London.pdf [accessed on 29th May 2015] 4 Venter C. Cows’ milk protein allergy and other food hypersensitivities in infants. Journal of Family Health Care 2009; 19(4): 128-134 5 Taylor et al. Cost-effectiveness of using an extensively hydrolysed formula compared to an amino acid formula as first-line treatment for cows’ milk allergy in the UK.

Pediatr Allergy Immunol 2012; 23(3): 240-9 6 Department of Health. Quality Innovation Productivity and Prevention (QIPP) in england. London, UK, 2012 www.rcn.org.uk/__data/assets/pdf_ file/0007/457900/13.12_QIPP_in_england.pdf 7 London Procurement Partnership. Paediatric appropriate prescribing for dietitians (online). www.lpp.nhs.uk/media/52668/Paediatric-appropriate-Prescribing-for-

Dietitians-compatibility-Mode-.pdf [accessed on 29th May 2015] 8 National Institute for Health and Clinical Excellence. Food allergy in children and young people: Diagnosis and assessment of food allergy in children and young people in primary care and community settings. London, UK, 2011 9 Paediatric Formulary Committee. BNF for Children (online). London: BMJ Group, Pharmaceutical Press, and RCPCH Publications www.medicinescomplete.com [accessed on 29th May 2015] 10 Fiocchi A, Schunemann HJ, Brozek J et al. Diagnosis and rationale for action against cows’ milk allergy (DRACMA): a summary report. J Allergy Clin Immunol 2010; 126: 11 19-28 11 Latcham et al. A consistent pattern of minor immunodeficiency and subtle enteropathy in children with multiple food allergy. J Pediatr 2003; 143: 39-47 12 Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications http://www.medicinescomplete. com [accessed on 29th May 2015] 13 Venter et al. Diagnosis and management of non-IgE-mediated cows’ milk allergy in infancy - a UK primary care practical guide. Clinical and Translational Allergy 2013 NHD Magazine_0515.ai 1 5/6/15 6:14 PM3: 23

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