A Puzzling ThingFood Allergies

Mary Beth Feuling, MS, RD, CNSDClinical Dietitian Specialist

Children’s Hospital of WisconsinTwin 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 IgEIn 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 III1976-80 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 USResults 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 responsesto 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

PrevalenceSignificant 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 impacton 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 over-reacting 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-MediatedIgE-Mediated Non-IgE MediatedNon-IgE Mediated

Oral Allergy Oral Allergy Syndrome Syndrome

AnaphylaxisAnaphylaxis

UrticariaUrticaria

Eosinophilic esophagitisEosinophilic esophagitis

Eosinophilic gastritisEosinophilic gastritis

Eosinophilic Eosinophilic gastroenteritisgastroenteritis

Atopic dermatitisAtopic dermatitis

Protein-Induced Protein-Induced EnterocolitisEnterocolitis

Protein-Induced Protein-Induced EnteropathyEnteropathy

Eosinophilic Eosinophilic proctitisproctitis

Dermatitis Dermatitis herpetiformisherpetiformis

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• AvoidanceCommon 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 testingSkin 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

Positive (?) Histor y Negative or low +RAST Food elimination diet Consider non - Nutritional evaluati on Consider GI evaluation Repeat SPT/RAST at intervals Nutritional evaluation Unchanged/increasing Decreasing levels Negative SPT

or accidental ingestion Continue elimination diet without symptoms

Food challenge

Positive Negative Continue Oral tolerance

elimination demonstrated diet Periodic food challenge

Complete history and physical exam

Skin prick testing (SPT) or R.A.S.T.

-IgE diseases

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

TwinjectTwinject®® or Adrenaclickor Adrenaclick® ®

autoinjectorautoinjector

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. Prep the skin with alcohol

B. Grip the “pen” with thumb on the black cap

C. Pull off the gray cap

D. 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 comeforward and epinephrinewill be ejected.)

EpiPenEpiPen/EpiPen/EpiPen Jr: Jr: Directions for UseDirections 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.

EpiPenEpiPen/EpiPen/EpiPen Jr: Jr: Directions for UseDirections 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 femalewith Down Syndrome plottedon 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

Restrictive Diets:Red Flags

Micronutrients

•Fat/essential fatty acids

•Iron

•Calcium/Vitamin D

•ZincMacronutrients: especially proteinUse 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 foodsAllergenic 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 MultivitaminsAll 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 seleniumNote: 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 AllergensEgg 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

Marsh-mallow

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 Sample Menu for 1-3 year old child with

milk, egg, peanut allergy (after dx)milk, egg, peanut allergy (after dx)

Problem Nutrients:

•Calories • Protein • Fat • Calcium • Vitamin D • Iron

Breakfast Lunch DinnerWhole 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

Multiple Food Allergies:Case Study

Nutrient AnalysisNutrient Intake prior to allergy dx Intake after allergy dx

Calories 1490 305

Protein 47 gm 5 gm

Fat 55 gm 2 gm

Calcium 1100 mg 98 mg

Vitamin D 203 IU 20 IU

Iron 9.9 mg 4 mg

Zinc 8.9 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 AnalysisNutrient Intake prior to allergy dx Intake with revised menu

Calories 1490 1360

Protein 47 gm 42 gm

Fat 55 gm 49 gm

Calcium 1100 mg 754 mg

Vitamin D 203 IU 285 IU

Iron 9.9 mg 10 mg

Zinc 8.9 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 hospitalizedcc: Poor oral intake; severe rashPMH: FT, birth wt 7 lb 11 oz

Frequent upper respiratory infectionsh/o poor wt gain starting at 6-8 months

Growth: Length 82 cm (50th%ile)Weight 10.4 kg (15th %ile)Wt/L 15th %ileWt @ 93% IBW/L

Food Intolerance:Case Study (cont)

Fdg Hx: Breast fed exclusively x 6-7 months of ageSimilac not toleratedSoy milk not toleratedAlimentum until 1 yr of ageRice milkSolids: normal progression except “picky eater”

Labs: Albumin 1.9 g/dl severe eczematous proteinmalnutritionHgb 10.7 8.8 g/dl, Hct 31.2 26.7% iron deficiencyZinc 420 mcg/L zinc deficiencySelenium 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 & ImmunologyWebsite: http://www.aaaai.org

• American Dietetic AssociationWebsite: http://www.eatright.org

• Asthma and Allergy Foundation of AmericaWebsite: http://www.aafa.org

• American Partnership For Eosinophilic Disorders Website: http://www.apfed.org

• American College of Allergy, Asthma & ImmunologyWebsite: 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 ResourcesUS 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 Over the Counter Medical ModuleCarbohydrate Infant cereal Polycose

Strained fruit ModucalPuddings Hydrous DextroseSyrup Fructose

Fat Oil, butter, margarine, gravy MicrolipidCream, sour cream LipomulSalad dressings, dips MCT OilAvocado, guacamoleOlives, Nut butters

Carb & Fat DuocalProtein Dry milk powder Beneprotein Egg

Strained meat CheeseCarb & Protein Carnation Instant Breakfast

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)

• 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 nutrition-associated 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.