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 ageRice 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. 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Support Care Cancer. 1997;5(6):504-5. References (Continued) • • • • • • • 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.