A Puzzling Thing
Food Allergies
Mary Beth Feuling, MS, RD, CNSD
Clinical Dietitian Specialist
Children’s Hospital of Wisconsin
Twin Cities District Dietetic Association Meeting
September 14, 2010
(No financial relationships to disclose)
Tonight’s Objectives:
 Discuss the nutritional impact of food allergies
 Recognize and understand the role of the
Dietitian
 Understand allergy testing options and the
impact on the food allergy patient
 Discuss current issues, controversies and
determine myths versus facts
What’s the story?
• “Telling Food Allergies From False
Alarms” (The New York Times)
• “Is Your Kid Truly Allergic? Tests Add
to Food Confusion” (The Wall Street Journal)
• “Adverse Reactions to Food: Allergies
& Intolerance” (Digestive Diseases)
• “’Allergic Girl’ teaches how to eat out
with allergies” (CNN.com)
What’s the story?
• “This allergies hysteria is just nuts” (British
Medical Journal)
• “Children at risk in food roulette”
(ChicagoTribune.com)
• “Fear and Allergies in the Lunchroom”
(Newsweek)
• “Food Allergen’s Attack” (Food Service Director)
• “Food Allergies Take a Toll on Families and
Finances” (The New York Times)
Key Points to Remember
•
•
•
•
Medical Nutrition Therapy - Roadblocks
Registered Dietitian – Important Role
Degree of Nutrition Risk
Compounded with other Medical
Conditions
History of Food Allergies
80 years ago Carl Prausnitz (who was not
allergic), injected serum from his fish
allergic colleague Heinz Küstner into his
own abdominal skin.
Prausnitz subsequently ate some cooked
fish. After several minutes hives developed
at the site of the serum injection.
History of Food Allergies
This clarified the fundamental basis of the
allergic mechanism
There was a “serum component”
responsible for allergy
In 1966 Ishizaka identified this as IgE
In 2003 first published anti-IgE trial in
peanut allergy
How do we answer…?
• Is it true that there’s more allergy now than
when I was a kid?
• Did I eat something while I was pregnant
that caused my child’s allergy? I craved
peanuts when I was pregnant…
• Can peanut allergy be outgrown?
NHANES II vs NHANES III
1976-80 vs 1988-94
Arbes SJ Jr et al: Prevalences of positive skin test responses to 10
common allergens in the US population: results from the third National
Health and Nutrition Examination Survey. J Allergy Clin Immunol
2005;116:377-83
Sensitization Rates in the US
Results of NHANES III
• 54.3% of the population have at least 1 positive SPT
• Of the allergens tested, prevalence was 2.1-5.5 times
higher in NHANES III vs II
• 8.6% population have a positive peanut test (not
tested in NHANES II)
Arbes SJ Jr et al: Prevalences of positive skin test responses
to 10 common allergens in the US population: results from the third
National Health and Nutrition Examination Survey. J Allergy Clin
Immunol 2005;116:377-83
Prevalence
Significant rise in atopic conditions in Westernized
countries over the past 20 years
Prevalence of peanut / tree nut allergy:
0.7% adults, 0.4% children: NY telephone survey
Sicherer SH et al: Prevalence of peanut and tree nut allergy in the
US determined by a random digit dial telephone survey.
J Allergy Clin Immunol. 1999 Apr;103(4):559-62.
Prevalence of shellfish allergy:
2% sensitivity to crustaceans (shrimp and lobster)
0.4% to finned fish
Sicherer SH et al: Prevalence of seafood allergy in the
United States determined by a random telephone survey.
J Allergy Clin Immunol 2004;114:159-165.
Isle of Wight
Popular from Victorian times
as a holiday resort, the Isle
of Wight is known for its
natural beauty and as home
to the Royal Yacht Squadron,
home to poet Alfred Lord
Tennyson and Queen
Victoria's much loved
summer residence. Its
maritime history
encompasses boat building
and sail making through to
the manufacture of flying
boats and the world's first
hovercraft.
Prevalence
Rising prevalence (U.K.):
1246 children skin tested on the Isle of Wight
Same geographic area evaluated 1989 & 1994
2 fold increase of reported peanut allergy
3 fold increase of peanut skin test sensitization
Grundy J et al: The rising prevalence of allergy to
peanut in children: Data from 2 sequential cohorts
J Allergy Clin Immunol 2002;110:784-9
Prevalence
• In 2007, 3 million children (4%) under 18 years
of age
– 18% higher than 1997
• Children = higher incidence of food allergies
than adults
• Children under 5 years of age = higher rates of
food allergies than those > 5 yrs
• Most children will “outgrow” their food allergies
Did I eat something while I was pregnant that
caused my child’s allergy? I craved peanuts
when I was pregnant…
Avoidance Diets and Prevention
• Most studies show a protective effect on atopy
by exclusive breast feeding
• However, delaying initial exposure to cereal
grains after 6 months may increase the risk of
developing wheat allergy
• Does low level exposure oral or via breast milk
or topical promote sensitization or tolerance?
Friedman NJ, Zeiger RS: The role of breast feeding in the development of allergies and
Asthma. J Allergy Clin Immunol 2005;115:1238-48
Poole JA et al: Timing of initial exposure to cereal grains and the risk of wheat allergy.
Pediatrics 2006;117:2175-82
Back to the Isle of Wight
• In 1998 the UK issued advice that pregnant or
nursing women with family history of atopy may
wish to avoid eating peanuts
• 858 births followed and SPT performed on 658 at
age 2
• 65% mothers avoided PN (1st time moms more
likely)
• 13 / 658 positive: incidence risk 2%
• In 10/13 (77%) of positive children, mothers had
avoided PN
Dean T, et al: Government advice on peanut avoidance
during pregnancy-is it followed correctly and what is the impact
on sensitization? J Hum Nutr Diet 2007;20:95-9
Is delivery by cesarean section a risk
factor for food allergy?
• Norwegian Birth Registry, 2803 children; 328
c-section births
• In the atopic mothers 4 fold increase egg
allergy
• Positive association between C-section and
persistent cow’s milk allergy (CMA)
Eggesbø M et al J Allergy Clin Immunol. 2003 Aug;112(2):420-6
Allergy. 2005 Sep;60(9):1172-3
Summary of Recommendations for
Prevention of Food Allergy
•
•
There is no evidence supporting avoidance or delays in food
introduction in children who are not high risk
Definition of high-risk infants:
– At least one parent or sibling with documented allergic disease
•
Maternal Lactation Diet:
– No dietary restrictions
•
Exclusive Breast Feeding:
– At least 4 months
•
Avoid Soy Formula:
– No *There is no convincing evidence for using soy based infant formulas for
allergy prevention.
•
Not Breast Fed or Supplemental Formula is needed:
– use hydrolyzed formula
• (extensively hydrolyzed/elemental is better than partially hydrolyzed; however
must weigh benefit versus cost)
• Delay introduction of solids: introduce solids between 4-6months of age. No
current convincing evidence that delaying their introduction beyond this period,
including those that are considered to be highly allergenic (egg, fish and foods
containing peanut protein).
(American Academy of Pediatrics Clinical Report January 2008; www.aap.org)
Allergy history:
Asking the right questions
• Timing of reaction: onset and duration
• Organs affected: localized vs systemic
• Location of reaction: home vs restaurant
• Severity of the reaction and response to treatment
• Prior history of food related reactions
• What was eaten?
• Amount eaten
What is a Food Allergy?
What is a food allergy?
• Individual’s immune system is overreacting to what is normally a harmless
food
• Response is related to the protein
component of a food
• Different from a “food intolerance”
– Lactose intolerance: GI symptoms from milk sugar not protein –
not an immune response. Often can tolerate 8 oz milk, low
lactose cheese (cheddar, colby) and yogurt with live, active
culture.
• Can be life threatening
Immunologic Reactions to Foods
IgE-Mediated
Non-IgE Mediated
Protein-Induced
Eosinophilic esophagitis Enterocolitis

Oral Allergy
Syndrome


Anaphylaxis

Urticaria

Eosinophilic gastritis
Eosinophilic
gastroenteritis


Atopic dermatitis
Protein-Induced
Enteropathy

Eosinophilic
proctitis

Dermatitis
herpetiformis

What is not a food allergy?
• Oral Allergy Syndrome
– Onset: older children and adults
– Relation to hay fever (sometimes)
– Symptoms
• Oral scratchiness and redness around the lips
– Treatment
• Avoidance
Common pollen – food associations
(grasses = tomato; ragweed = melons, kiwi,
banana)
What is not a food allergy?
• Irritant Dermatitis
– Not a food allergy
– Acidic foods cause red patches around
mouth and chin
• Grapefruit
• Orange
• Tomato
Food Allergy in the
United States
• 6-8% of children under age 4; 4% of adults
– Perception of the public 20-25%
– 1 in 17 children under 3 years of age has food
allergy
• 8 foods account for 90% of all food-allergic
reactions
• Some food allergies persist throughout life
Source: NCHS Data Brief, No. 10, October 2008
Major Food Allergens
• Egg
• Milk
• Peanut/Tree
nut
• Fish/Shellfish
• Soy
• Wheat
Allergenic Foods
• Almost every major food allergen identified
is a protein or glycoprotein
• Tend to resist denaturation by heat or acid
• Less common: other legumes, sesame,
poppy seed, sunflower seed, pine nuts,
mustard seed
Table of cross reactive foods
Sicherer SH: J Allergy Clin Immunol, 2001
How are food allergies
diagnosed?
• Blood tests
– RAST (Radioallergosorbent test)
• Serum IgE levels
• Skin tests
– Scratch tests (Skin Prick Test)
• Food Challenge
– Controlled
• Parental observations
– Clinical symptoms
Skin prick testing
Photos with patient permission
Symptoms of Food Allergy
(when exposed)
•
•
•
•
•
•
Hives
Eczema (dry, itchy skin)
Asthma
Vomiting, diarrhea, abdominal cramping
Red rash around mouth
Anaphylaxis (a life-threatening reaction)
Logarithm for the evaluation of suspected food reactions
Complete history and physical exam
Skin prick testing (SPT) or R.A.S.T.
Positive
(?) Histor y
or low +RAST
Negative
Food elimination diet
Consider non -IgE
- diseases
Nutritional evaluati on
Consider GI evaluation
Repeat SPT/RAST
at intervals
Unchanged/increasing
Continue elimination diet
Nutritional evaluation
Decreasing levels
Negative SPT
or accidental ingestion
without symptoms
Food challenge
Positive
Negative
Continue
elimination
diet
Oral tolerance
demonstrated
Periodic food
challenge
Development of Tolerance
• 10-20% Peanut allergic
• 80% by 8-10 years of age for other foods
• 50% by 5 years of age
– Based on office food challenge
Fatalities in Anaphylaxis
• Food anaphylaxis is the leading cause of
anaphylaxis treated in ED: 30,000/yr with 150-200
deaths (Sampson et al. Pediatrics 2003 111:1601-8)
• Peanut, tree nut, seafood account for most of these
reactions
Fatal Food-Induced
Anaphylaxis
• 32 cases of fatal anaphylaxis reviewed
• Most were adolescents or young adults
• Peanuts, tree nuts caused >90% of reactions
• 2/3 with asthma
• Most did not have epinephrine available or did
not use it.
(Bock SA, et al. J Allergy Clin Immunol 2001;107:191–193)
Food-induced Anaphylaxis:
Prevention
•
Learn to read product labels
•
Avoid high-risk foods that are more likely to contain a food
allergen
– (e.g, baked goods, foods from deli’s)
•
Avoid sharing food, utensils, or food containers
•
Must always be prepared to treat a reaction
– Have an emergency action plan
– Keep epinephrine on hand at all times
– Train caregivers and teachers on epinephrine use
– Wear MedicAlert bracelet
EpiPen® 2-Pak
Twinject® or Adrenaclick®
autoinjector
Epi Pen Jr® and Epi Pen®
Question: The first step in the use of
the EpiPen auto injector in the
treatment of acute anaphylaxis is:
A.
B.
C.
D.
Prep the skin with alcohol
Grip the “pen” with thumb on the black cap
Pull off the gray cap
Take a deep breath and check your pulse
EpiPen/EpiPen Jr:
Directions for Use
Remove the Gray or Blue
safety / activation cap.
Black or Orange tip
should NOT be touched.
(Pressure will cause the
needle to come
forward and epinephrine
will be ejected.)
EpiPen/EpiPen Jr:
Directions for Use
Place the Black or
Orange tip near the
fleshy outer portion of
the thigh.
It is not necessary to
remove clothing or to
prep the skin.
EpiPen/EpiPen Jr:
Directions for Use
Push firmly
at a 90
degree
angle to the
thigh
Hold for 10
seconds
Call 911
Treatment of Food allergies
The only treatment for food allergies at this time is to
totally avoid ingestion and exposure to identified
allergen.
- Avoid the food
- Careful meal planning
- Read food labels
- Ask about food preparation
- Be prepared for emergencies
Allergist and Dietitian
• Accurate diagnosis of causative foods
• Institution of elimination/prevention diet
• Assessment of proper emergency
treatment and development of “action
plans”
• Treatment of associated atopic disorders
• Assessment of nutritional status
• Education
Nutrition and Food Allergies
• Restricted diets will affect nutrient intake
• Feeding a child safe food can be difficult
with a food allergy diagnosis
• Diagnosis of food allergies can increase
stress for both the patient and family
• With education, many, many, people live
full and happy lives with food allergies!
Food allergies in children affect
nutrient intake and growth
L. Christie; R.J. Hine; J.G. Parker; W. Burks
• Compared height, weight, and BMI of children
with food allergies to control subjects
• Results:
– children with >2 food hypersensitivity (FH) were shorter than
those with 1 FH
– >25% children in both groups consumed <67% DRI for
calcium, Vit. D, Vit. E
– Less possibility of low calcium or vitamin D intake with nutrition
counseling or if prescribed a safe infant/toddler formula or
fortified soy beverage
• Conclusion
– Children diagnosed with food allergy need an
annual nutrition assessment to prevent growth
problems or inadequate nutrient intake
J Am Dietetic Assoc;2002
Nutrition Principles
• All children require same nutrients for
growth, development, and health
• Children with special needs may require
more or less of specific nutrients
• Nutrients can be adequately provided with
a variety of feeding plans
• Focus on “key” nutrients to decrease risk
of nutrition-related problems
Nutrition Principles
Nutrients
• Calories
• Protein
• Carbohydrate
• Fat
• Vitamins (13)
• Minerals (19)
• Water
Key Nutrients
• Calories
• Protein
• Fat
• Calcium
• Iron
• Zinc
• Fluid
• Fiber
Identifying “Red Flags”
Primary nutrition concern for all children:
altered growth
More specific nutrition concerns for:
•Delayed advance of diet
•Restricted diets
•Picky eating
Growth Assessment
•Obtain accurate measurements
•Serial measurements are best
•Plot all measurements on appropriate growth
charts
•Length or height, weight, weight/length, BMI
•CDC growth charts: standard of care
•Specialty growth charts: Down Syndrome, Turner
Syndrome, spastic CP, Achondroplasia, etc
•Use height age to establish weight and
nutrition goals
Value of serial measurements
Comparison of growth charts
for two girls with same
length & weight at 18 months.
● Normal growth rate
 Deceleration in growth rate
Using Correct Growth Chart
Weights for 18 month female
with Down Syndrome plotted
on CDC Growth Chart.
Suggests poor growth.
Using Correct Growth Chart
Same female infant with
Down’s Syndrome plotted
on Down Growth Chart
Shows acceptable growth
Nutrition Assessment
• Assessment of Nutritional Intake
– Diet History
•
•
•
•
24 hour recall
3 day food record
Formula or supplement use
Food habits, recent changes,
restrictions in the home
Nutritional Intake Standards
• DRIs (Dietary Reference Intakes)
– National Academy of Sciences (NAS) began revisions in 1997
– Revisions replace previous RDA set in 1941
– Reflect current research and emphasize beneficial outcomes of
adequate nutrition vs. prevention of deficiency
– Calories
– Protein
– Fat (1-2 yrs: >35% total calories)
– Vitamins, Minerals and Trace Elements
– http://www.iom.edu/Object.File/Master/21/372/0.pdf
Nutrition Assessment Checklist
• How many foods?
– Any exceptions recommended by the allergist?
• Can the child eat the protein as in ingredient in the food?
(baked egg or milk in cookies, cakes, muffins etc.)
•
•
•
•
What does the child drink?
Is it feasible to meet nutritional goals?
Are there any feeding problems?
Where is supplementation necessary?
– Specialized formula
– Vitamin and mineral supplementation
– Oil supplementation
Questions to Ask: Assessing Nutritional Risk
How many foods need to be avoided?
Risk increases with more foods being/needing to be avoided
What is the impact on nutrients?
Risk increases with more of the following nutrients being impacted or fewer
nutrients being severely impacted
Calories
Protein
Fat
Micronutrients
Are there other concerns about food intake?
Risk increases with other medical and psychological diagnoses affecting
intake
Swallowing/chewing difficulties
Psychological diagnoses affecting intake
Feeding disorder
Appropriate Distribution of Macronutrients
Imbalanced Macronutrient Distribution
Fat
Protein
Carbohydrate
Fat
Protein
Carbohydrate
Restrictive Diets:
Red Flags
Micronutrients
•Fat/essential fatty acids
•Iron
•Calcium/Vitamin D
•Zinc
Macronutrients: especially protein
Use of potentially harmful supplements
Key micronutrients provided by the most common food
allergens and alternative food sources that can serve as food
substitutes for the allergenic foods
Allergenic foods Micronutrients provided
Appropriate food substitutes
Milk
vitamin A, vitamin D, riboflavin,
pantothenic acid, vitamin B12,
calcium, phosphorus
meats, legumes, whole grains, nuts,
fortified foods/beverages (with B
vitamins, calcium and vitamin D)
Egg
vitamin B12, riboflavin,
pantothenic acid, biotin, selenium
meats, legumes, whole grains
Soy
thiamin, riboflavin, pyridoxine,
folate, calcium, phosphorus,
magnesium, iron, zinc
meats, legumes
Wheat
thiamin, riboflavin, niacin, iron,
folate if fortified
alternative fortified grains (barley,
rice, oat, corn, rye, quinoa, , soy)
and potatoes
Peanut/Tree
nut
vitamin E, niacin, magnesium,
manganese, chromium
whole grains, vegetable oils
Fish/Shellfish
vitamin B6, vitamin E, niacin,
phosphorus, selenium, omega-3
fatty acids
whole grains, meats, oils, soybean,
flaxseed, nuts
Milk Alternatives/Formulas
• Milk Alternatives
–
–
–
–
Soy milk (~300 mg Calcium)
Rice milk (~200 mg Calcium)
Almond milk (~300 mg Calcium)
Calcium fortified fruit juice (100-300 mg Calcium)
• Careful selection based on assessment of age, growth and
intake of other nutrients. Many are inappropriate for the child
under 2 years of age.
• Caution: protein content is variable
• Toddler Soy Formulas (Bright Beginnings Pediatric Soy Drink)
• Hydrolyzed Formula (Alimentum, Nutramigen, Vital Jr, Peptamin Jr)
• Amino Acid Based Formulas (Neocate, Elecare, Neocate Jr,
EO28 Splash)
Allergen Free Multivitamins
All of these products are free of milk, soy, egg, wheat,
peanut, tree nut, fish, and shellfish
•
•
•
•
•
One-A-Day Scooby Do Complete
One-A-Day Bugs Bunny Complete
Flintstone Children's Chewable Complete
NanoVM (1-3 yrs and 4-8 yrs)*#
Nature's Plus Animal Parade Children's
Chewable
*This product is only available online
# This is the only allergen-free vitamin that contains selenium
Note: Products can change at any time and labels should be read before use
Education, Education,
Education!
• Cornerstone for compliance and a
nutritionally adequate diet
Essential Information
•
•
•
•
•
•
Substitutions/alternatives for nutrient goals
How to read food labels (every time!!)
Forms of food/ingredients to avoid
Foods/ingredients to include
Meal and snack planning
Cross-contact/cross-contamination/hidden
foods
• Tips for eating out
• Recipes
• Resources and Support Groups
Impact of a Restricted Diet
Grocery Shopping
Cooking
Socializing
Travel/Vacations
Dining away from home
Schools, child care, and camps
Family Relationships
Lotions, Pet foods etc.
The Food Allergen and Consumer
Protection Act (FALCPA)
Can you trust it?
The Food Allergen and Consumer Protection Act
(FALCPA)
•
Effective January 1, 2006
•
Identify 8 major food allergens
•
Milk, Egg, Peanut, Tree Nut, Fish, Shellfish, Wheat
and Soy
•
Identify presence in spices, flavorings etc
•
“May contain” or “processed on” - voluntary
•
Gluten-free not included at this time
How to Read the Food Label
•
•
•
•
Download: www.foodallergy.org
Updated at least annually
Be aware of “hidden” sources of allergens
Remember, must read labels for
everything
– Medications, vitamins, toothpaste, lotions,
mouthwash, etc
• Read labels every time!
Label Reading
• Regulated by the FDA
• Can be listed “within” or “at the end” of the
ingredient statement
• DON’T rely on the “contains” statement
• Foods prepared by bakery, deli, etc may
or may not list all ingredients
“May Contain” is an unknown risk
avoid unless you obtain more
information
• “manufactured on the same equipment
as…”
• “manufactured in the same facility as…”
• “any allergen not listed on the ingredient
statement” !??
Source: Food Allergy Research and Resource Program 2003
Common Sources of Hidden Food Allergens
Egg
Milk
Nuts
Soy
Wheat
Rice
Pasta
Bread/
bread
crumbs
Cereals
Bread/
Bread
Crumbs
Cereals
Baby
food
Breads
Cereals
Egg
rolls
Waffles
Gluten
free
products
Breads
Egg
Beaters
Candy/
Chocolate
Cakes/
cookies
Crackers
Hot dogs/
low fat
beef
franks
Cake/
Muffin
mixes
Candy
Frozen
Desserts
Frozen
Dessert
Chicken
hot dogs/
low fat
beef
franks
Soy sauce
Waffles
Marshmallow
Canned
Tuna
Nut
butters
Cake/
muffins
BBQ
potato
chip
Soups
Waffles
Processed
meats
Sauces/
chili
Bouillon
cubes
Modified
Food
starch
Cross-Contact
(Cross-Contamination)
• If you don’t know what is in the
food…..don’t give it to the child
• Ask questions about preparation
• Ask to read the label
• Make NO assumptions!
Cross Contact
(Cross Contamination)
• Food manufacturer’s equipment
• Restaurants, delis, bakeries are high risk
– counters, equipment, frying oils, utensils, grills
– secret ingredients, bulk bins
• School/daycare settings
– Art projects with food
– Careless food preparation
Multiple Food Allergy Case Study:
Sample Menu for 1-3 year old Child
(prior to allergy dx)
Breakfast
Lunch
Dinner
Whole milk
Cereal
Banana
Whole milk
Peanut butter and jelly
sandwich
Cooked carrots, butter
Strawberries
Whole milk
Meatloaf
Dinner roll, butter
Peas
Mashed potatoes
Snack
Granola bar
Juice
Snack
Yogurt drink
Oatmeal cookie
Snack
Ice cream
Sample Menu for 1-3 year old child with
milk, egg, peanut allergy (after dx)
Breakfast
Lunch
Dinner
Whole milk
Cereal
Banana
Whole milk
Peanut butter and jelly
sandwich
Cooked carrots, butter
Strawberries
Whole milk
Meatloaf
Dinner roll, butter
Peas
Mashed potatoes
Snack
Granola bar
Juice
Snack
Yogurt drink
Oatmeal cookie
Snack
Ice cream
Problem Nutrients:
•Calories • Protein • Fat • Calcium • Vitamin D • Iron
Multiple Food Allergies:
Case Study
Nutrient Analysis
Nutrient
Calories
Protein
Fat
Calcium
Vitamin D
Iron
Zinc
Intake prior to allergy dx
1490
47 gm
55 gm
1100 mg
203 IU
9.9 mg
8.9 mg
Intake after allergy dx
305
5 gm
2 gm
98 mg
20 IU
4 mg
2.6 mg
Revised menu for 1-3 year old child with
milk, egg, peanut allergy
Breakfast
Lunch
Dinner
Enriched soy milk
Cereal
Banana
Enriched soy milk
Soy nut butter and
jelly sandwich
Cooked carrots
Strawberries
Enriched soy milk
MF/EF meatloaf with
ketchup
MF Dinner roll with MF
margarine
Peas
Mashed potatoes
(made with chicken
broth)
Snack
Teddy Grahams
Orange juice
Snack
Soy yogurt
FAAN Oatmeal
cookie
Snack
Soy ice cream
Multiple Food Allergies:
Case Study
Nutrient Analysis
Nutrient
Calories
Protein
Fat
Calcium
Vitamin D
Iron
Zinc
Intake prior to allergy dx
1490
47 gm
55 gm
1100 mg
203 IU
9.9 mg
8.9 mg
Intake with revised menu
1360
42 gm
49 gm
754 mg
285 IU
10 mg
6 mg
TIPS for the Parent/Caregiver
•
•
•
•
•
Start a notebook
Start with single ingredient foods
Make lists
Read labels every time
Encouragement - Don’t give up!
Steps for Dinning Out
1) Call or Google the specific Restaurant
2) Ask if there is a website
3) Request the menu be emailed or
faxed
4) Request the Manager’s name & a
good time to call with questions
5) Review the menu and determine
which items might be safe
Steps for Dinning Out
6) Call the Manager to ask Questions:
a) Ask experience with food allergies
b) How is the food item prepared?
c) Is there a specific server to request?
7) Parent & child should decide which
foods to order
8) Tell Manager when you plan to come
Steps for Dinning Out
9) When you arrive – ask for Manager &
identify yourself
10)When the waitperson comes to the
table, tell them about the preliminary
contact with the Manager, that the
child has life-threatening food
allergies, hand them a dining card and
that you pre-determined the order.
11)Child should wear a medical alert
bracelet
Dinning Cards
• Food Allergy Buddy (FAB) Dinning Card
Website:
http://www.foodallergybuddy.com
• Make your own
– Be sure to clearly list the food allergies your
child is avoiding
Tips for Traveling
•
•
•
•
•
•
Plan out meals ahead of time.
Stay at hotels that offer kitchenettes to prepare foods
in the room.
Find a natural food store in the area.
For those who need them, make sure a supply of
epinephrine autoinjectors is available at all times,
along with an emergency action plan. Keep them
protected from excessive heat or cold during the trip.
Make sure the child wears a medical identification
bracelet in case he becomes lost or has an allergic
reaction.
Don't be afraid to speak out about the child's food
allergies. Talk to managers at restaurants, hotels,
etc., as to how food should be handled. When in
doubt, walk out and find another place that is more
comfortable dining.
Travel Cards in Different
Languages
• www.selectwisely.com
• www.dietarycard.co.uk
• www.allergytranslation.com
What to Buy? Where to Shop?
• Local Grocery Store
• Specialty Stores
– Such as Whole Foods
• Internet Shopping and Research:
www.peanutfreeplanet.com
www.allergygrocer.com
Things to consider in a
school setting
• Work together with school staff to provide safe foods and
environment (www.foodallergy.org : free resources)
• Simplify meals and snacks with supply of safe foods
• Identify and train staff who provide care to food allergic
child – education is key
• Include food allergic child in activities but be creative
with food activities
• Make sure staff is aware of allergies and can recognize
signs of reaction
• Have an ACTION PLAN ready in case of accidental
exposure
Prevention tips
• Wash hands frequently
• Post allergy information in food prep areas
• Designate allergen free eating area
– Lunch buddies
• Discourage food trading
• Distribute guidelines about foods brought
from home to share
Food Allergies and Nutrition Support
Two possible scenarios
• a child with known food allergies requires
nutrition support
• allergies to formula or parenteral nutrition
components become apparent only after
the commencement of nutrition support
Enteral Nutrition
• most enteral formulas contain cow’s milk
protein
• children with cow’s milk protein allergies
can be managed with soy protein, protein
hydrolysates or elemental formulas
Enteral Nutrition
• formula intolerances that occur in young children
receiving nutrition support are probably
secondary to food allergies
• management strategies for formula intolerances
include a transition to a hydrolysate/elemental
formula, which may result in resolution of the
acute situation
• food allergy is diagnosed retrospectively when
the child cannot be transitioned back to a more
standard formula
Parenteral Nutrition
• There are minimal data on parenteral nutrition
support in children with documented allergies to
foods
• Two foods, eggs and soy, could be a cause for
concern since both can be found in intravenous
lipid solutions
Parenteral Nutrition
Egg Allergy
Three options could be considered:
• consultation with an allergist who may or
may not do a prick test
• lipid-free PN
• use of Liposyn II
Parenteral Nutrition
Soy Allergy
Most will probably tolerate IV lipids but
consider:
• consultation with an allergist
• lipid-free PN
Parenteral Nutrition
A variety of allergies to parenteral nutrition have been
described through case reports in the literature
They appear to be more common in children
Skin rashes appear to be the most common manifestation
Other manifestations include dyspnea, cyanosis, nausea,
vomiting, headache, flushing, fever, and chest pain
Anaphylaxis can occur
Parenteral Nutrition
Reactions can occur:
• at the first administration
• after several days of administration
• after reinstitution following a hiatus
Parenteral Nutrition
These reactions have been attributed to:
• intravenous lipid preparations
• crystalline amino acid solutions
• multivitamin mixtures (either due to stabilizers
and emulsifiers in the Pediatric MVI or due to
vitamin K)
Parenteral Nutrition
If reaction occurs:
– stop the parenteral nutrition
– administer appropriate drug treatment for the allergic
reaction
If the reaction is severe and the patient is going
to continue to require parenteral nutrition:
– Institute a multidisciplinary approach utilizing:
• allergist
• pharmacist
• nutrition-support physician and/or dietitian
Parenteral Nutrition
If the reaction is mild and resolves
after parenteral nutrition is discontinued,
there are two options:
– have skin prick testing of the lipid, multivitamin,
and amino acid components and removal of the
offending agent(s) before parenteral nutrition is
restarted
– identify the offending agent through trial and
error
Intravenous Iron
• cause significant allergic reactions
• allergic reactions can be associated with:
– iron dextran
– sodium ferric gluconate complex in sucrose
– iron sucrose
Food Intolerance:
Case Study
18 month old male hospitalized
cc:
Poor oral intake; severe rash
PMH:
FT, birth wt 7 lb 11 oz
Frequent upper respiratory infections
h/o poor wt gain starting at 6-8 months
Growth:
Length
82 cm (50th%ile)
Weight
10.4 kg (15th %ile)
Wt/L
15th %ile
Wt @
93% IBW/L
Food Intolerance:
Case Study (cont)
Fdg Hx:
Breast fed exclusively x 6-7 months of age
Similac not tolerated
Soy milk not tolerated
Alimentum until 1 yr of ageRice milk
Solids: normal progression except “picky eater”
Labs:
Albumin 1.9 g/dl severe eczematous protein
malnutrition
Hgb 10.7 8.8 g/dl, Hct 31.2 26.7%  iron deficiency
Zinc 420 mcg/L  zinc deficiency
Selenium level undetectable  selenium deficiency
Plan:
NG feeds of Peptamen Jr  Pediasure 
Oral supplement of Pediasure age appropriate diet
Food Allergy
Resources
• Food Allergy & Anaphylaxis Network
www.foodallergy.org
www.fanteen.org
www.fankids.org
www.faancollegenetwork.org
1-800-929-4040
• School Food Allergy Program – free
to schools in US
• FAAN Anaphylaxis video
• Annual Conferences for
Parents/Caregivers/Professionals
Food Allergy Resources
• Food Allergy & Anaphylaxis Network
Website: http://www.foodallergy.org
• American Academy of Allergy, Asthma & Immunology
Website: http://www.aaaai.org
• American Dietetic Association
Website: http://www.eatright.org
• Asthma and Allergy Foundation of America
Website: http://www.aafa.org
• American Partnership For Eosinophilic Disorders
Website: http://www.apfed.org
• American College of Allergy, Asthma & Immunology
Website: http://www.acaai.org
Food Allergy Resources
• National Eczema Association for Science and Education
Website: http://nationaleczema.org
• MedicAlert Foundation International
Website: http://www.medicalert.org
• ID on me Medic Alert Braclets
Website: http://www.idonme.com
• The American Academy of Pediatrics
Website: http://wwwaap.org
• National Jewish Medical and Research Center
Website: http://www.nationaljewish.org
Food Allergy Resources
US Government Resources
• Healthfinder: Your Guide to Reliable
Healthcare Information
– www.healthfinder.gov
• Medline Plus: Food Allergy
– www.nlm.nih.gov/medlineplus/foodallergy.html
• U.S.D.A. Food and Nutrition Information
Center
– www.nal.usda.gov/fnic/etext/fnic.html
Food Allergy Resources
• Children’s Hospital of Wisconsin
– http://chw.org
– Click: Health Information, Patient Handouts
– Search key words: allergy, asthma, eczema
– Feeding Your Baby 0-12 months
– Feeding Your Toddler 1- 3 years
– Calcium in Your Child’s Diet
– Increasing Iron in Your Child’s Diet
– Increasing Fiber in Your Child’s Diet
– Eosinophilic Esophagitis
Appendices
•
•
•
•
Food Fortifiers
Calorie Boosters
Increasing protein
Increasing fat
•
•
•
•
Increasing fluid
Increasing fiber
Increasing iron
Increasing calcium
Food Fortifiers
Nutrient
Carbohydrate
Fat
Carb & Fat
Protein
Carb & Protein
Over the Counter
Infant cereal
Strained fruit
Puddings
Syrup
Oil, butter, margarine, gravy
Cream, sour cream
Salad dressings, dips
Avocado, guacamole
Olives, Nut butters
Dry milk powder
Egg
Strained meat
Cheese
Carnation Instant Breakfast
Medical Module
Polycose
Moducal
Hydrous Dextrose
Fructose
Microlipid
Lipomul
MCT Oil
Duocal
Beneprotein
Calorie Boosters
•Carnation Instant Breakfast
•Fortified milks
•Cheese: grated, melted, shredded (milk or soy
protein based)
•Butter, margarines, oils, gravy, sour cream,
salad dressings
•Puddings, ice cream, shakes
•Avocado, guacamole, olives, nut butters
Protein Boosters
•Milk, cheese, yogurt, soy based products
(yogurt, cheese, pudding)
•Eggs
•Nut butters and Sunbutter (sunflower seeds)
•Sandwich spreads
•Meats: strained, ground
•Variety of beans
Fat Boosters
•Fat should be >30% of calorie intake
•Minimize use of low fat and “light foods”
•Additional oil added to foods
•Prevent essential fatty acid deficiency
•Linoleic acid (ω6): 1-2.7% total calories
•Alpha Linolenic (ω3): 0.54-1% total calories
•Suggested vegetable oil combination: soybean or
corn + canola oil
Increasing Fiber
•Fiber Goal: Individualize
•Rule of Thumb: Age + 5 grams
•Provide adequate fluid first, then fiber
•Higher fiber foods include:
•Bran, whole grains
•Fruits/vegetables
•Blenderize when needed
•Use formula with fiber
•Use fiber supplement
Increasing Iron
•Heme iron better absorbed than non-heme
iron
•Sources of heme iron
•Meat, chicken, fish
•Sources of non-heme iron
•Whole grain breads and cereals, wheat germ,
fortified breads & cereals
•Foods rich in Vitamin C can help improve
absorption of non-heme iron
References
•
•
•
•
•
Branum AM, Lukacs SL. Food allergy among U.S. children:
Trends in prevalence and hospitalizations. NCHS data brief, no
10. Hyattsville, MD: National Center for Health Statistics. 2008.
Arbes SJ Jr, Gergen PJ, Elliott L, Zeldin DC. Prevalences of
positive skin test responses to 10 common allergens in the US
population: results from the third National Health and Nutrition
Examination Survey. J Allergy Clin Immunol 2005;116(2):377-83
Sicherer SH, Muñoz-Furlong A, Burks AW, Sampson HA.
Prevalence of peanut and tree nut allergy in the US determined by
a random digit dial telephone survey. J Allergy Clin Immunol.
1999;103(4):559-62.
Sicherer SH, Muñoz-Furlong A, Sampson HA. Prevalence of
seafood allergy in the United States determined by a random
telephone survey. J Allergy Clin Immunol 2004;114(1):159-165.
Sicherer SH, Furlong TJ Burks AW, Sampson HA. A voluntary
registry for peanut and tree nut allergy: characteristics of the first
5149 registrants. J Allergy Clin Immunol. 2001; 108(1):128-32.
References (Continued)
•
•
•
•
•
•
Hubbard S. Nutrition and food allergies: the dietitian’s role. Ann Allergy
Asthma Immunol. 2003;90(6 Suppl 3):115-6.
Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect
nutrient intake and growth. J Am Diet Assoc. 2002;102(11):1648-51
Joshi P, Mofidi S, Sicherer SH. Interpretation of commercial food
ingredient labels by parents of food-allergic children. JJ Allergy Clin
Immunol. 2002; 109(6):920-2.
Food Allergy Issues Alliance. Food Allergen Labeling Guidelines.
Washington, DC: National Food Processors Association 2001Buchman
AL, Ament ME. Comparative hypersensitivity in intravenous lipid
emulsions. JPEN J Parenter Enteral Nutr. 1991;15(3):345-6.
Nagata MJ. Hypersensitivity reactions associated with parenteral
nutrition: case report and review of the literature. Ann Pharmacother.
1993;27(2):174-7.
Weidmann B, Lepique C, Heider A, Schmitz A, Niederle N.
Hypersensitivity reactions to parenteral lipid solutions. Support Care
Cancer. 1997;5(6):504-5.
References (Continued)
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•
•
•
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•
•
Scolapio JS, Ferrone M, Gillham RA. Urticaria associated with parenteral
nutrition. JPEN J Parenter Enteral Nutr. 2005;29(6):451-3.
Bullock L, Etchason E, Fitzgerald JF, McGuire WA. Case report of an
allergic reaction to parenteral nutrition in a pediatric patient. JPEN J
Parenter Enteral Nutr. 1990;14(1):98-100.
Pomeranz S, Gimmon Z, Ben Zvi A, Katz S. Parenteral nutrition-induced
anaphylaxis. JPEN J Parenter Enteral Nutr. 1987;11(3):314-5.
Market AD, Lew DB, Schropp KP, Hak EB. Parenteral nutritionassociated anaphylaxis in a 4-year-old child. J Pediatr Gastroenterol
Nutr. 1998;26(2):229-31.
Andersen HL, Nissen I. Presumed anaphylactic shock after infusion of
Lipofundin. Ugeskr Laeger. 1993;155(28):2210-1.
Silverstein SB, Rodgers GM. Parenteral iron therapy options. Am J
Hematol. 2004;76(1):74-8.
Bailie GR, Clark JA, Lane CE, Lane PL. Hypersensitivity reactions and
deaths associated with intravenous iron preparations. Nephrol Dial
Transplant. 2005;20(7):1443-9.
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Nutrition: The Building Blocks of Feeding