Avoiding the Avoiding the Offending Offending AllergenAllergen

Ingredient Lists and Labelling LawsIngredient Lists and Labelling Laws

2

Canada’s Food Labelling Canada’s Food Labelling LawsLaws

On February 16th 2011 Health Canada On February 16th 2011 Health Canada Published Amendments to the Food Allergen Published Amendments to the Food Allergen Labelling Regulations in Labelling Regulations in Canada GazetteCanada Gazette, Part , Part II (CGII)II (CGII)

The new Regulations were designed to The new Regulations were designed to enhance labelling requirements for specific enhance labelling requirements for specific priority allergens, gluten sources and added priority allergens, gluten sources and added sulphites in prepackaged foods sold in Canadasulphites in prepackaged foods sold in Canada

The new food allergen labelling regulations The new food allergen labelling regulations came into force on August 4, 2012came into force on August 4, 2012

http://www.hc-sc.gc.ca/fn-an/label-etiquet/allergen/index-eng.php

3

Reasons for the New Reasons for the New LawsLaws

Health Canada's policy for enhancing the Health Canada's policy for enhancing the protection of food-allergic consumers in protection of food-allergic consumers in Canada is based on two guiding principles:Canada is based on two guiding principles:

Prevent the inadvertent consumption of Prevent the inadvertent consumption of undeclared allergens by sensitive consumersundeclared allergens by sensitive consumers

Enable a variety of safe and nutritious food Enable a variety of safe and nutritious food choices for the allergic consumerchoices for the allergic consumer

4

Ten Priority AllergensTen Priority Allergens

The list of priority allergens now includes:The list of priority allergens now includes: PeanutsPeanuts Tree nuts (almonds, Brazil nuts, cashews, hazelnuts, Tree nuts (almonds, Brazil nuts, cashews, hazelnuts,

macadamia nuts, pecans, pine nuts, pistachios, macadamia nuts, pecans, pine nuts, pistachios, walnuts)walnuts)

MilkMilk EggsEggs Seafood (fish, crustaceans, shellfish)Seafood (fish, crustaceans, shellfish) SoySoy WheatWheat Sesame seedsSesame seeds MustardMustard SulphitesSulphites

5

Labelling of "hidden" Labelling of "hidden" priority allergenspriority allergens

Previously, food labels did not have to declare when a Previously, food labels did not have to declare when a priority allergen was used to make an ingredient like priority allergen was used to make an ingredient like spices or flavoursspices or flavours

Now, labels on products will have to let consumers Now, labels on products will have to let consumers know when these allergens are in the product, either know when these allergens are in the product, either in the ingredient list or in a "contains" statementin the ingredient list or in a "contains" statement

The allergen may appear in the ingredient listThe allergen may appear in the ingredient list Components of an ingredient like spices may be in Components of an ingredient like spices may be in

bracketsbrackets And/or the allergen may appear in a "contains" And/or the allergen may appear in a "contains"

statement after the ingredients, like "Contains: XX” statement after the ingredients, like "Contains: XX”

6

Plain LanguagePlain Language Previously a number of names for an ingredient, Previously a number of names for an ingredient,

some of which were unfamiliar to the general public, some of which were unfamiliar to the general public, could appear on labelscould appear on labels E.g. “casein”, whey”, “lactalbumin”, “lactose”, etcE.g. “casein”, whey”, “lactalbumin”, “lactose”, etc

With the new food labels, companies will have to use With the new food labels, companies will have to use commonly understood names for the priority commonly understood names for the priority allergensallergens E.g. for the ingredients above, E.g. for the ingredients above, “milk”“milk” must appear on the must appear on the

labellabel The names, such as "wheat" or "milk," will have to be The names, such as "wheat" or "milk," will have to be

used either in the ingredient list or in the "contains" used either in the ingredient list or in the "contains" statementstatement

Some manufacturers include them in bothSome manufacturers include them in both

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Precautionary Precautionary StatementsStatements

Previously a number of precautionary statements Previously a number of precautionary statements appeared on labels, eg:appeared on labels, eg: May contain trace amounts of [X]May contain trace amounts of [X] Produced on shared equipment with [X] Produced on shared equipment with [X] Manufactured in a facility that also manufactures [X]Manufactured in a facility that also manufactures [X]

Health Canada and the CFIA are recommending that Health Canada and the CFIA are recommending that food manufacturers and importers begin to use only food manufacturers and importers begin to use only

one precautionary statement on food labels:one precautionary statement on food labels:

"may contain [X]""may contain [X]"

where X is the name by which the allergen is commonly where X is the name by which the allergen is commonly known known

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““Natural” FoodsNatural” Foods Nature", "natural", "Mother Nature", "Nature's Way" Nature", "natural", "Mother Nature", "Nature's Way"

are terms often misused on labels and in are terms often misused on labels and in advertisementsadvertisements

““Advertisements should not convey the impression Advertisements should not convey the impression that "Nature" has, by some miraculous process, made that "Nature" has, by some miraculous process, made some foods nutritionally superior to others or has some foods nutritionally superior to others or has engineered some foods specially to take care of engineered some foods specially to take care of human needs”human needs”

Some consumers may consider foods described as Some consumers may consider foods described as "natural" of greater worth than foods not so described"natural" of greater worth than foods not so described

http://www.inspection.gc.ca/english/fssa/labeti/guide/ch4ae.shtml

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Manufactured FoodsManufactured Foods Foods or ingredients of foods submitted to processes Foods or ingredients of foods submitted to processes

that have significantly altered their original physical, that have significantly altered their original physical, chemical or biological state should not be described chemical or biological state should not be described as "natural“as "natural“ E.g: the removal of caffeine from coffeeE.g: the removal of caffeine from coffee

A natural food or ingredient of a food is not expected A natural food or ingredient of a food is not expected to contain, or to ever have contained, an to contain, or to ever have contained, an added added vitamin, mineral nutrient, artificial flavouring vitamin, mineral nutrient, artificial flavouring agent or food additive.agent or food additive.

A natural food or ingredient of a food does not have A natural food or ingredient of a food does not have any constituent or fraction thereof any constituent or fraction thereof removedremoved or or significantly changedsignificantly changed, except the removal of water, except the removal of water

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““Natural” AdditivesNatural” Additives Some food additives, vitamins and mineral nutrients Some food additives, vitamins and mineral nutrients

may be derived from natural sourcesmay be derived from natural sources Some of these additives may be regarded as natural Some of these additives may be regarded as natural

ingredients, in which case the acceptable claim would ingredients, in which case the acceptable claim would be that this food contains be that this food contains "natural ingredients“"natural ingredients“

If the additive is derived from a priority allergen, the If the additive is derived from a priority allergen, the allergen must be listed on the labelallergen must be listed on the label

Note that while the ingredient can be described as Note that while the ingredient can be described as "natural", the food itself cannot, since it contains an "natural", the food itself cannot, since it contains an added component.added component.

The list of ingredients of such foods must declare The list of ingredients of such foods must declare acids, bases, salts or sweeteners which are present by acids, bases, salts or sweeteners which are present by their their proper common namesproper common names

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Food Additive Food Additive IngredientsIngredients

Food additives are considered ingredients in any pre-Food additives are considered ingredients in any pre-packaged food and must be:packaged food and must be: Included in the ingredients’ listIncluded in the ingredients’ list Listed by the common name associated with the Listed by the common name associated with the

active ingredient in the preparationactive ingredient in the preparation In general, food ingredients are listed in descending In general, food ingredients are listed in descending

order of proportion by weightorder of proportion by weight However, food additives, spices, seasonings, herbs However, food additives, spices, seasonings, herbs

(except salt), natural and artificial flavours, flavour (except salt), natural and artificial flavours, flavour enhancers, vitamins and mineral nutrients and their enhancers, vitamins and mineral nutrients and their derivatives and salts, may be placed at the end of the derivatives and salts, may be placed at the end of the ingredients list in any orderingredients list in any order

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Food AdditivesFood Additives

Foods meant for human consumption may Foods meant for human consumption may contain additives under the GRAS (generally contain additives under the GRAS (generally recognized as safe) designationrecognized as safe) designation

Level of food additives may be allowed Level of food additives may be allowed according to “good manufacturing practices”:according to “good manufacturing practices”: Amount determined by standards for the productAmount determined by standards for the product E.g: annatto is added to butter to the amount E.g: annatto is added to butter to the amount

required to bring it to an established standard required to bring it to an established standard yellow colouryellow colour

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Levels of additives Levels of additives permitted in foodspermitted in foods

Others will have upper limits determined for Others will have upper limits determined for each food type, e.g.each food type, e.g. Benzoic acid in jams and juices not to exceed Benzoic acid in jams and juices not to exceed

1,000 ppm1,000 ppm Nitrites in preserved meats not to exceed 200 ppmNitrites in preserved meats not to exceed 200 ppm

Whatever the limit, the presence of the Whatever the limit, the presence of the additive will be indicated on the food labeladditive will be indicated on the food label

http://www.hc-sc.gc.ca/fn-an/securit/addit/list/11-preserv-conserv-eng.php

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Food ColoursFood Colours Three colours must be listed by name:Three colours must be listed by name:

AnnattoAnnatto Allura redAllura red Sunset yellowSunset yellow

One or more of the other allowed food colours may One or more of the other allowed food colours may be listed in the ingredients simply as “colour” be listed in the ingredients simply as “colour”

Regulations provide food manufacturers with the Regulations provide food manufacturers with the choice of declaring added colours by either their choice of declaring added colours by either their common name or simply as "colour"common name or simply as "colour"

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Artificial Food Dyes Artificial Food Dyes Permitted in CanadaPermitted in Canada

AlkanetAlkanet Allura redAllura red Aluminum metalAluminum metal AmaranthAmaranth AnthocyaninAnthocyanin Brilliant blueBrilliant blue CanthaxanthineCanthaxanthine Carbon blackCarbon black Citrus red #2Citrus red #2 CochinealCochineal

ErythrosineErythrosine Fast greenFast green IndigotineIndigotine Iron oxideIron oxide OrchilOrchil PonceauPonceau SaunderswoodSaunderswood Sunset yellowSunset yellow TartrazineTartrazine

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SulphitesSulphites

The following sulphites, singly or in combination may The following sulphites, singly or in combination may be listed as “sulphiting agents” or “sulphites”:be listed as “sulphiting agents” or “sulphites”: Potassium bisulphitePotassium bisulphite Potassium metabisulphitePotassium metabisulphite Sodium bisulphiteSodium bisulphite Sodium metabisulphiteSodium metabisulphite Sodium sulphiteSodium sulphite Sodium dithioniteSodium dithionite Sulphurous acidSulphurous acid Sulphur dioxideSulphur dioxide

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Monosodium glutamate Monosodium glutamate (MSG)(MSG)

There are no regulations requiring this flavour There are no regulations requiring this flavour to be identified specificallyto be identified specifically

Manufacturers can list the additive by the Manufacturers can list the additive by the source, e.g.source, e.g. Hydrolysed vegetable protein (HVP)Hydrolysed vegetable protein (HVP) Hydrolysed plant protein (HPP)Hydrolysed plant protein (HPP) Hydrolysed soy protein (HSP)Hydrolysed soy protein (HSP)

If the hydrolysate is derived from a priority If the hydrolysate is derived from a priority allergen it should appear on the labelallergen it should appear on the label HSP should identify “soy” as an allergenHSP should identify “soy” as an allergen

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Chicken noodle soup mix

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GrissolMelba Toast

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Chicken noodle soup mix

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Food ServicesFood Services

Role of the dietitian is to ensure all meals Role of the dietitian is to ensure all meals provided to identified food allergic individuals provided to identified food allergic individuals are free from their offending allergensare free from their offending allergens

Concern when patients designate food Concern when patients designate food aversions as “allergies”aversions as “allergies”

Request confirmation of allergy from medical Request confirmation of allergy from medical practitioner if necessarypractitioner if necessary

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Identification of Identification of AllergensAllergens

Computer coding, example:Computer coding, example: List of ingredients with allergens identified in side-by-side List of ingredients with allergens identified in side-by-side

columnscolumns List priority allergens List priority allergens List allergens of common concern, e.g.List allergens of common concern, e.g.

CornCorn RiceRice Individual meats, fruits, vegetablesIndividual meats, fruits, vegetables

List additives of concern, e.g.List additives of concern, e.g. SulphitesSulphites MSGMSG TartrazineTartrazine

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What about secondary What about secondary ingredients?ingredients?

If not listed on label, need not include as If not listed on label, need not include as allergens, e.g.allergens, e.g. Sulphite in fruit purSulphite in fruit purééee

If label identifies a priority allergen in a If label identifies a priority allergen in a precautionary statement (as “may contain”) list precautionary statement (as “may contain”) list as allergen presentas allergen present

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Food PreparationFood Preparation

Is it practical to designate areas as allergen-Is it practical to designate areas as allergen-free?free? Which allergens should be excluded?Which allergens should be excluded? All priority allergens?All priority allergens?

Are all prepackaged and preprepared foods Are all prepackaged and preprepared foods entering the facility adequately labelled?entering the facility adequately labelled?

How can meals on an assembly line be How can meals on an assembly line be considered “allergen-free”considered “allergen-free”

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Precautionary Precautionary StatementsStatements

Dietitian can only ensure that an allergic Dietitian can only ensure that an allergic patient’s meals are free from patient’s meals are free from knownknown sources of sources of the allergenthe allergen Contamination from foods prepared in the same Contamination from foods prepared in the same

area cannot be avoidedarea cannot be avoided ““Prepared in a facility that also processes Prepared in a facility that also processes

foods containing [X]”foods containing [X]” New labelling rules suggest this should read, New labelling rules suggest this should read,

“may contain [X]”“may contain [X]”

PREVENTION OF PREVENTION OF ALLERGYALLERGY

Recent Changes in DirectionRecent Changes in Direction

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Prevention of Allergy:Prevention of Allergy:Historical PerspectiveHistorical Perspective

Measures of prevention were all designed to Measures of prevention were all designed to avoid avoid sensitizationsensitization to allergens during what were to allergens during what were considered the most vulnerable periods:considered the most vulnerable periods: Intra-uterine lifeIntra-uterine life From birth to 2-3 yearsFrom birth to 2-3 years

This meant reduction in This meant reduction in exposureexposure to highly allergenic to highly allergenic foods:foods: Mother’s diet during pregnancy and lactationMother’s diet during pregnancy and lactation Delay in introduction of highly allergenic foods during Delay in introduction of highly allergenic foods during

weaningweaning In spite of these stringent measures to prevent allergy, In spite of these stringent measures to prevent allergy,

incidence of all types of allergies have increased incidence of all types of allergies have increased significantlysignificantly

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Change in Direction During Change in Direction During the Past Five Yearsthe Past Five Years

Understanding of the importance of immunological Understanding of the importance of immunological sensitizationsensitization and and tolerancetolerance

Recognition that Recognition that tolerancetolerance not not sensitizationsensitization is the is the critical step in allergy preventioncritical step in allergy prevention

Finding that Finding that exposureexposure to the allergenic food at an to the allergenic food at an optimum stage is probably a critical step in optimum stage is probably a critical step in allergy allergy preventionprevention

Recognition that tolerance can be induced after Recognition that tolerance can be induced after allergy has been established – leading to important allergy has been established – leading to important measures for measures for allergy managementallergy management

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Allergy is a Response of the Allergy is a Response of the Immune SystemImmune System

Our immune systems are designed to protect Our immune systems are designed to protect the body from invasion by foreign materialsthe body from invasion by foreign materials

All foods contain proteins – derived from All foods contain proteins – derived from plants and animals – all of which are foreign to plants and animals – all of which are foreign to the human bodythe human body

In order for food to be absorbed, metabolized, In order for food to be absorbed, metabolized, and utilized by the body, the immune system and utilized by the body, the immune system needs to be “educated” that the foreign needs to be “educated” that the foreign material is safematerial is safe

________Herz 2008

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Oral ToleranceOral Tolerance

““Education” of the T cells to not respond Education” of the T cells to not respond to that food protein when it enters via the to that food protein when it enters via the oral route – called oral route – called oral toleranceoral tolerance

Contrasts with the Contrasts with the active immune active immune responsesresponses needed to protect the gut needed to protect the gut against continual bombardment by against continual bombardment by invading pathogens and their products invading pathogens and their products (toxins, etc)(toxins, etc)

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Prevention of Food Allergy in Prevention of Food Allergy in Clinical PracticeClinical Practice

Significant changeSignificant change in directives within the past 5 in directives within the past 5 years:years:

Previously: Previously: Avoidance of allergen to Avoidance of allergen to prevent prevent

sensitizationsensitization (allergen-specific IgE) (allergen-specific IgE) Current: Current:

Active stimulation of the immature Active stimulation of the immature immune system to immune system to induce toleranceinduce tolerance of the of the antigens in foodantigens in food

________________Rautava et al 2005

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Factors Predictive of Allergy:Factors Predictive of Allergy:High and Low risk GroupsHigh and Low risk Groups

Many factors investigated as possible Many factors investigated as possible predictive markers for allergypredictive markers for allergy

Only significant variable in studies:Only significant variable in studies:Family history of allergyFamily history of allergy (all types) (all types)

High risk for allergy:High risk for allergy: One first degree relative with diagnosed One first degree relative with diagnosed

allergy (IgE-mediated) of any typeallergy (IgE-mediated) of any type First-degree relative: parent or siblingFirst-degree relative: parent or sibling

33

When does Tolerance of When does Tolerance of Foods Begin?Foods Begin?

Food proteins demonstrated to cross the Food proteins demonstrated to cross the placenta and can be detected in amniotic placenta and can be detected in amniotic fluidfluid

Exposure to small quantities of food Exposure to small quantities of food antigens from mother’s diet thought to antigens from mother’s diet thought to tolerize the fetustolerize the fetus, by means of IgG1 and , by means of IgG1 and IgG3, within a “protected environment”IgG3, within a “protected environment”

34

Diet During PregnancyDiet During Pregnancy

Current directive: the atopic mother should strictly Current directive: the atopic mother should strictly avoid her own allergens and replace the foods with avoid her own allergens and replace the foods with nutritionally equivalent substitutesnutritionally equivalent substitutes

There are There are no indicationsno indications for mother to avoid other for mother to avoid other foods during pregnancyfoods during pregnancy

A nutritionally complete, well-balanced diet is A nutritionally complete, well-balanced diet is essentialessential

Authorities recommend avoidance of Authorities recommend avoidance of excessiveexcessive intake intake of highly allergenic foods such as peanuts and nuts to of highly allergenic foods such as peanuts and nuts to prevent “allergen overload”, but there is no scientific prevent “allergen overload”, but there is no scientific data to support thisdata to support this

_______________Kramer et al 2006

_______________Sicherer et al 2010

35

Implications of Research DataImplications of Research Data

Exclusive breast-feeding with exclusion of Exclusive breast-feeding with exclusion of mother’s and baby’s allergens will reduce signs of mother’s and baby’s allergens will reduce signs of allergy in the first 1-2 years; specifically:allergy in the first 1-2 years; specifically: Cow’s milk allergyCow’s milk allergy Eczema (atopic dermatitis)Eczema (atopic dermatitis)

Reduction or prevention of early food allergy by Reduction or prevention of early food allergy by breast-feeding does not seem to have long-term breast-feeding does not seem to have long-term effects on the development of:effects on the development of: AsthmaAsthma Allergic rhinitis (hay fever)Allergic rhinitis (hay fever)

Exclusive breast-feeding for 4-6 months is Exclusive breast-feeding for 4-6 months is strongly encouragedstrongly encouraged

36

Summary of 2008 AAP Guidelines Summary of 2008 AAP Guidelines for Allergy Management for Allergy Management [Greer et al [Greer et al

2008]2008]

There is no convincing evidence that There is no convincing evidence that women who avoid highly allergenic women who avoid highly allergenic foods, or other foods during foods, or other foods during pregnancy and breast-feeding lower pregnancy and breast-feeding lower their child’s risk of allergiestheir child’s risk of allergies

_____________Greer et al 2008

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Value of Breast-feedingValue of Breast-feeding

For high-risk for allergy infants (one For high-risk for allergy infants (one first-degree relative with established first-degree relative with established allergy), exclusive breast-feeding for at allergy), exclusive breast-feeding for at least 4 months prevents or delays the least 4 months prevents or delays the occurrence of:occurrence of: Atopic dermatitis (eczema)Atopic dermatitis (eczema) Cow’s milk allergy (CMA)Cow’s milk allergy (CMA) WheezingWheezing

____________________Sicherer and Burks 2008

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Preventive Effect of Breast-Preventive Effect of Breast-feeding:feeding:

KOALA StudyKOALA Study Longer duration of breastfeeding is associated with Longer duration of breastfeeding is associated with

lower risk for lower risk for eczemaeczema in non-atopic mothers in non-atopic mothers Slightly lower risk for mothers with allergy but no Slightly lower risk for mothers with allergy but no

asthmaasthma Longer duration of breastfeeding reduced risk for Longer duration of breastfeeding reduced risk for

wheezingwheezing in infants: possibly due to reduction in in infants: possibly due to reduction in respiratory infectionsrespiratory infections

There is a lack of evidence that exclusive or There is a lack of evidence that exclusive or prolonged breast-feeding has any positive effect on prolonged breast-feeding has any positive effect on the development of the development of asthmaasthma in older children in older children

___________________________Snijders et al 2007 KOALA study

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Summary of 2008 AAP Summary of 2008 AAP Guidelines Guidelines continuedcontinued

In infants at high risk for allergy who are not In infants at high risk for allergy who are not exclusively breast-fed for 4-6 months there is exclusively breast-fed for 4-6 months there is modest evidence that the onset of allergy, modest evidence that the onset of allergy, especially especially eczemaeczema, may be delayed or , may be delayed or prevented by the use of hydrolyzed formulasprevented by the use of hydrolyzed formulas

There is no good evidence that soy-based There is no good evidence that soy-based infant formulas have any preventive effect on infant formulas have any preventive effect on the development of allergythe development of allergy

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Preventive Effect of Preventive Effect of Hydrolyzed Infant FormulaeHydrolyzed Infant Formulae

No evidence of any reduction in allergy with No evidence of any reduction in allergy with hydrolyzed formula compared to breastfeedinghydrolyzed formula compared to breastfeeding

Limited evidence that prolonged feeding with Limited evidence that prolonged feeding with hydrolyzed formula compared to cow’s milk reduces hydrolyzed formula compared to cow’s milk reduces incidence of incidence of CMA and eczemaCMA and eczema

No evidence that hydrolyzed formulas have any No evidence that hydrolyzed formulas have any effect on the development of effect on the development of rhinitis and asthmarhinitis and asthma later later

Extensively hydrolyzed cow’s milk (Ehf) formulas Extensively hydrolyzed cow’s milk (Ehf) formulas better than partially hydrolyzed whey (Phf) in better than partially hydrolyzed whey (Phf) in prevention prevention

_________________________________Osborn and Sinn 2009 Cochrane Review

__________________________Von Berg et al GINI Study 2009

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Infant Formulae for the Infant Formulae for the Allergic BabyAllergic BabyCurrent RecommendationsCurrent Recommendations

Cow’s milk based formula if there are no signs Cow’s milk based formula if there are no signs of milk allergyof milk allergy

Partially hydrolysed (phf) whey-based formula Partially hydrolysed (phf) whey-based formula if there are no signs of milk allergy in high risk if there are no signs of milk allergy in high risk for allergy groupfor allergy group

Extensively hydrolysed (ehf) casein based Extensively hydrolysed (ehf) casein based formula if milk allergy is proven formula if milk allergy is proven

_________________Greer et al AAP 2008Von Berg et al 2007

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Recommendations for Recommendations for Introduction of Solids to High Risk Introduction of Solids to High Risk

for Allergy Infantsfor Allergy Infants

Little evidence that delaying the introduction of Little evidence that delaying the introduction of complementary foods beyond 4-6 months of age complementary foods beyond 4-6 months of age prevents allergyprevents allergy

Introduction of solid foods should be individualizedIntroduction of solid foods should be individualized Foods should be introduced one at a time in small Foods should be introduced one at a time in small

amountsamounts Mixed foods containing various potential food Mixed foods containing various potential food

allergens should not be given unless tolerance to each allergens should not be given unless tolerance to each ingredient has been assessedingredient has been assessed

____________________Greer et al AAP 2008

_____________________Thygaran and Burks 2008

43

Introduction of Solid Foods in Introduction of Solid Foods in Relationship to Celiac DiseaseRelationship to Celiac Disease

Results suggest that in high risk for celiac disease Results suggest that in high risk for celiac disease infants introduction of gluten-containing grains infants introduction of gluten-containing grains before 3 months or after 7 months increases before 3 months or after 7 months increases incidences of development of CDincidences of development of CD11

Introduction of gluten while breast-feeding offers Introduction of gluten while breast-feeding offers protection or delays onset of celiac disease in at-risk protection or delays onset of celiac disease in at-risk infantsinfants22

Recommendations: Recommendations: Introduce gluten grains in small amounts between 4 and 6 Introduce gluten grains in small amounts between 4 and 6

months while infant is breastfedmonths while infant is breastfed Continue breast-feeding for a further 2-3 monthsContinue breast-feeding for a further 2-3 months

Similar results for wheat allergySimilar results for wheat allergy33

_______________1Norris et al 2005

______________2Guandalini 2007

____________3Poole et al 2006

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Introduction of PeanutsIntroduction of Peanuts Directives from pediatric societies (1998 - 2007) Directives from pediatric societies (1998 - 2007)

recommended avoidance of peanuts by mothers recommended avoidance of peanuts by mothers during pregnancy and lactation, and delaying during pregnancy and lactation, and delaying introduction of peanuts until after 2 or even 3 years of introduction of peanuts until after 2 or even 3 years of ageage

Research indicates that incidence of peanut allergy in Research indicates that incidence of peanut allergy in children rose dramatically in the years following children rose dramatically in the years following release of these directivesrelease of these directives

Recent research suggests:Recent research suggests: Avoidance of peanuts reduced development of toleranceAvoidance of peanuts reduced development of tolerance Early exposure leads to reduced incidence of peanut allergyEarly exposure leads to reduced incidence of peanut allergy

_________________Hourihane et al 2007 ______________

Du Toit et al 2008

45

Introduction of FishIntroduction of Fish

Historically, fish consumption during infancy was Historically, fish consumption during infancy was considered to be a risk factor for allergyconsidered to be a risk factor for allergy

Recent research indicates otherwise:Recent research indicates otherwise: Regular fish consumption during the first year of life Regular fish consumption during the first year of life

associated with a reduced risk for allergic disease by age 4 associated with a reduced risk for allergic disease by age 4 years (n=4089)years (n=4089)11

Babies of mothers who frequently consumed fish (2-3 Babies of mothers who frequently consumed fish (2-3 times per week or more) during pregnancy had one third times per week or more) during pregnancy had one third less food sensitivities than those whose mothers did not less food sensitivities than those whose mothers did not consume fish during pregnancyconsume fish during pregnancy22

_____________1Kull et al 2006

_______________2Calvani et al 2006

46

The Natural History of Food The Natural History of Food AllergyAllergy

Food allergy most often begins in the first 1 to Food allergy most often begins in the first 1 to 2 years of life2 years of life

Child is sensitized to the food protein by the Child is sensitized to the food protein by the immune system developing allergen-specific immune system developing allergen-specific IgE to that proteinIgE to that protein

Sensitization does not necessarily mean that Sensitization does not necessarily mean that the child will develop symptoms when that the child will develop symptoms when that food is eatenfood is eaten

Over time most food allergy is lostOver time most food allergy is lost_________Wood 2003

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PrognosisPrognosis Most children outgrow early food allergyMost children outgrow early food allergy

John’s Hopkins Children’s Center USAJohn’s Hopkins Children’s Center USA Milk allergy outgrown:Milk allergy outgrown:

20% by 4 years20% by 4 years 42% by 8 years42% by 8 years 79% by 16 years79% by 16 years

Egg allergy outgrown:Egg allergy outgrown: 4% by 4 years4% by 4 years 37% by 10 years37% by 10 years 68% by 16 years68% by 16 years

Allergy to some foods more often than others persists into Allergy to some foods more often than others persists into adulthoodadulthood:: PeanutPeanut Tree nuts Tree nuts SeedsSeeds ShellfishShellfish FishFish

______________Skripak et al 2007

48

Induction of Oral Induction of Oral ToleranceTolerance

Tolerance to a specific food can be induced by Tolerance to a specific food can be induced by oral administration of the offending food by oral administration of the offending food by process of “low dose continuous exposure”process of “low dose continuous exposure”

Designated (SOTI: specific oral tolerance Designated (SOTI: specific oral tolerance induction)induction)

Starting with very low dosagesStarting with very low dosages Gradually increasing daily dosage up to the Gradually increasing daily dosage up to the

equivalent of the usual daily intakeequivalent of the usual daily intake Followed by daily maintenance doseFollowed by daily maintenance dose

__________________Niggemann et al 2006

48

_____________Calvani et al 2010

49

Oral Tolerance Induction to Oral Tolerance Induction to Milk, Egg, and PeanutMilk, Egg, and Peanut

36% of children with IgE-mediated allergy to 36% of children with IgE-mediated allergy to cow’s cow’s milkmilk and and hen’s egghen’s egg developed permanent tolerance of developed permanent tolerance of the foods after a median 21 months specific oral the foods after a median 21 months specific oral tolerance induction (SOTI)tolerance induction (SOTI)11

4 peanut-allergic children underwent SOTI:4 peanut-allergic children underwent SOTI: Daily doses of Daily doses of peanut flourpeanut flour starting at 5 mg peanut protein starting at 5 mg peanut protein 2-weekly dosage increase up to 800 mg protein2-weekly dosage increase up to 800 mg protein All subjects tolerated at least 10 whole peanuts (2.38 g All subjects tolerated at least 10 whole peanuts (2.38 g

protein) on post-intervention challengeprotein) on post-intervention challenge22

______________1Staden et al 2007

______________22Clark et al 2009 49

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Progression of Peanut AllergyProgression of Peanut Allergy

Peanut allergy, like many early food allergies, can be Peanut allergy, like many early food allergies, can be outgrownoutgrown

In 2001 pediatric allergists in the U.S. reported that In 2001 pediatric allergists in the U.S. reported that about 21.5 per cent of children will eventually about 21.5 per cent of children will eventually outgrow their peanut allergyoutgrow their peanut allergy11

Those with a mild peanut allergy, as determined by Those with a mild peanut allergy, as determined by the level of peanut-specific IgE in their blood, have a the level of peanut-specific IgE in their blood, have a 50% chance of outgrowing the allergy50% chance of outgrowing the allergy22

Only about 9% of patients are reported to outgrow Only about 9% of patients are reported to outgrow their allergy to tree nutstheir allergy to tree nuts33

__________________1Skolnick et al 20012Fleischer et al 20033Fleischer et al 2005 50

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Maintaining Tolerance of Maintaining Tolerance of PeanutPeanut

When there is no longer any evidence of symptoms When there is no longer any evidence of symptoms developing after a child has consumed peanuts, it is developing after a child has consumed peanuts, it is preferable for that child to preferable for that child to eat peanuts regularlyeat peanuts regularly, , rather than avoid them, in order to maintain tolerance rather than avoid them, in order to maintain tolerance to the peanutto the peanut

Children who outgrow peanut allergy are at risk for Children who outgrow peanut allergy are at risk for recurrence, but the risk has been shown to be recurrence, but the risk has been shown to be significantly higher for those who significantly higher for those who continue to avoid continue to avoid peanutspeanuts after resolution of their symptoms after resolution of their symptoms

_________________Fleischer et al 2004

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