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WHAT CAN AN ALLERGY DIETITIAN DO FOR YOU ?
Rosan Meyer (RD, PhD)
Paediatric Allergy Dietitian
Chair of Food Allergy Specialist Group
Honorary Senior Lecturer
Imperial College London
November 2016
CARE PATHWAY FOR FOOD ALLERGY
Standard managementi. Allergy specific advice ii. Optimisation of prevention and treatment of further reactions - written personalmanagement plan/training iii. Minimising impact on quality of lifeiv. Nutritional support and monitoring by registered dietitianv. Management of co-morbidities vi. Additional patient/carer support vii. Communication with other agencies viii. Onward referral and liaison, if required ix. Further care, as detailed below
Complex Management (MDT setting) i. Involvement of clinical nurse specialist in paediatric allergy ii. Involvement/referral to allied healthcare professionals, ideally in joint allergy clinicse.g. specialist paediatric allergy dietitian iii. Expert psychosocial support iv. Further care, as detailed below
WHERE DOES AN ALLERGY DIETITIAN FIT INTO PRACTICE?
Diagnosis• Allergy Focused Diet History• Elimination diet• Food ChallengesNutritional AssessmentManagement• Elimination Diet – Management• Nutritional AdequacyTolerance• Food Challenge
Niggemann, B et al. Who should manage infants and young children with food induced symptoms. Arch Dis Child 2006;91:379-382
DIETITIANS AS PART OF MULTIDISCIPLINARY CLINICS
Denton et al. 2014: pro and cons for dietitians to be part of a multidisciplinary team that offers a “one-stop” children’s food allergy service
236 children with FHS (1.4 months and 16 year) were seen 162 by dietitians and 74 by paediatricians.
57.1% reported difficulties managing their child’s diet before they had had any dietetic consultation
67.6% indicated that an earlier appointment would have been helpful
82.9% of parents/carers indicated that a one-stop clinic would be helpful and 17.1% disagreeing
Denton et al. Nursing children and Young People 2014;26:16-23
EVIDENCE OF DIETITIAN MAKING A DIFFERENCE IN FOOD ALLERGY
Canani et al. 2014: performed non-randomized multicentre interventional study to assess effect of dietary counselling in food allergic children:
At enrolment, energy and protein intakes were lower in children with FA than controls
6 months following dietary counselling: the total energy intake of children with FA increased and was similar to
controls
significant improvement anthropometric parameters
Laboratory biomarkers of nutritional status improved
Canani et al. J Acad Nutr Diet. 2014;114:1432-1439.
EVIDENCE OF DIETITIAN MAKING A DIFFERENCE IN FOOD ALLERGY
Tarkin et al. BSACI 2014: established impact of dietetic counselling on growth and weaning foods in food allergic children
Growth Parameter Mean (+/-SD) z-score
p value
Weight for Height (WHZ) before -0.07 (+/-0.91) 0.034
Weight for Height (WHZ) after 0.11 (+/-0.86)
Height for Age (HAZ) before -0.69 (+/-1.77) 0.016
Height for Age (HAZ) after -0.37 (+/-1.63)
Weight for Age (WAZ) before -0.55 (+/-1.29) 0.0001
Weight for Age (WAZ) after -0.17 (+/-1.18)
Head Circumference for age (HCZ) before
-0.31 (+/-1.44) 0.017
Head Circumference for age (HCZ) after
-0.02 (+/- 1.35)
NICE GUIDANCE 116– FOOD ALLERGY
‘For babies and young children with suspected allergy to cows’ milk protein, offer: food avoidance advice to breastfeeding mothers information on the most appropriate hypoallergenic formula or milk substitute to mothers of formula-fed babies.Seek advice from a dietitian with appropriate competencies’
WHAT IS AN ALLERGY DIETITIAN?
Dietitians dealing with allergy are: Hospital based: secondary and tertiary care
Primary care
EAACI working on competencies for Allied Healthcare Professionals working in Allergy
BDA competency based course on CMPA – 6 Feb 2017
Many courses specifically for dietitians by Allergy Academy, Gastro Academy and BDA
MSc in Allergy or Module on Food Hypersensitivity
Adult Children
Reeves et al. Clinical and Translational Allergy (2015) 5:4
https://www.imperial.ac.uk/medicine/study/postgraduate/masters-programmes/msc-pg-cert-allergy/
Do you want to become an expert in Allergy?
Register your interest with our Course Administrator - [email protected]
RESOURCES FOR DIETITIANS AND TO HCP
FASG diet sheets
Public sheets
Linked into a network of dietitians that can help
CASE 1
9 month old child is breast fed and has IgE mediated allergy – had lip swelling and rash 3x after introduction of yoghurt at 6 months and SPT = 12 mm, soya 4 mm, peanut 10 mm (no symptoms before this age)
Mum needs to go back to work and requires a hypoallergenic formula
How can your dietitian help in this case?
> 6 months of age it is significantly harder to introduce hypoallergenic formula so parents will need help to introduce and to pick the correct formula
Practical advice on how to do this and which formula
Clinical presentation
MAP guidelines (primary care)1st choice
BSACI Guidelines (secondary and tertiary care) 1st choice
DRACMA
1st choice
ESPGHAN
1st choice
Anaphylaxis AAF AAF AAF AAF
Acute urticaria or angioedema
Mild-moderate eHFSevere +/- poor growth AAF
eHF eHFNo specific mention, but eHF in general as 1st line
Atopic eczema/dermatitis
Mild-moderate eHFSevere +/- poor growth AAF
If breastfed AAF otherwise eHF
eHFNo specific mention, but eHF in general as 1st line treatment
EoE AAF AAF AAF AAF (for EGID)
Gastroesophagealreflux disease
Mild-moderate eHFSevere +/- poor growth AAF
eHF eHFNo specific mention but eHF in general as 1st line treatment
Cow’s milk protein-induced enteropathy
Mild-moderate eHFSevere +/- poor growth AAF
eHF unless severe in which case AAF
eHFAAF (complicated by growth faltering)
FPIES
Mild-moderate eHFSevere +/- poor growth AAF
AAF eHF AAF
Proctocolitis
Mild-moderate eHFSevere +/- poor growth AAF
eHF eHFNo specific mention, but eHF in general as 1st line treatment
CASE 1 – DIETETIC ADVICE
Meyer et al. Current Allergy & Clinical Immunology, March 2012 Vol 25, No. 1
Please have a look at MAP guidelines
for primary care and BSACI guidelines
for secondary and tertiary care.
Case 1 – ingredients in hypoallergenic formulas that may impact on choice
• MCT is hydrolysed much faster by intestinal digestive juices and pancreatic lipase than LCT:• Optimises absorption of lipids in patients with malabsorptive disorders
• MCT increases osmolality of feeds also affects palatability
• Lactose – improves palatability and gut bacterial flora
• Additional iron (follow-on formulas)
• Additional calcium/vitamin D
• Prebiotics (GOS/FOS mixture)
• Probiotics – LGG, need to mix < 40C – this has been approved by ACBS
CASE 2
Baby F is 10 months of age and has severe eczema and Food Protein Induced Enterocolitis Syndrome to multiple foods.
His growth is faltering and is on a hypoallergenic formula already
He is currently needs to avoid milk, soya, egg, nut, wheat, rice, oat and sweet potato
How can your dietitian help with this child?
CASE 2 – DIETARY ADVICE
Dietary intake assessment – often diets are excessively
limited to only a few foods because of fear of reactions
Advice on optimal food allergen avoidance
Advice on what the child can eat
Practical guidelines for nursery/child minder
Recipes
How to increase the energy and protein content
Supplementation: Vit A,D, Calcium, iron, zinc
Venter and Meyer. Proceedings of the Nutrition Society (2010), 69, 11–24
Springston et al. Ann Allergy Asthma Immunol. 2010;105:287–294
CASE 2 - ALTERNATIVES
CASE 3 – GROWTH FALTERING
34-45% of energy and 35-47% of protein come from hypoallergenic formulas 91% of children who consumed sufficient volume
hypoallergenic formula met recommended intake for nutrients Modular additions to feed: carbohydrate and fat blends + fat (LCT/MCT) Up to 5 g/100ml (aimed at achieving ± 100 kcal/100 ml)
Concentration of feeds – 20% concentration ± 4 scoops per 100 ml
Isolauri et al. J Pediatr 1998;132:1004-9
CASE 3 GROWTH FALTERING – IMPACT OF FEED MODULATION
Energy:Protein ratio disturbed ++ (< 6% of energy from protein, guidance from the WHO = 8-12% for catch-up growth)
Weight gain = fat mass and limited LBM Dehydration = ↑ Renal Solute Load Diarrhoea + vomiting
Osmolality ↑ (> 400 mOsm/kg) Accuracy of mixing at home Taste?? Adding just fat and energy is not going to lead to optimal catch up
growthJeff SG. Journal of the Royal College of General
Practitioners, 1989, 39, 113.
CASE 3
Patient V is 15 months of age and continues on an amino acid formula and has a milk and peanut allergy
Current guidelines suggest a hypoallergenic formula until 2y years of age but this is very expensive to continue prescribing
What can a dietitian do for you? Meyer et al. Clin Transl Allergy 2014;4:31
CASE 3 – OVER THE COUNTER MILKS
Meyer R. Complete Nutrition 2014;13(6):53-58.
CASE 4
Baby L is 1 year old and has non-IgE mediated allergies. You gave the MAP milk ladder
Mum said that she is not keen on the foods high sugar content and they rarely eat lasagne
How can the dietitian help you here?
Provide recipe for baked biscuit with less sugar
but same amount of cow’s milk protein
Provide alternatives to lasagne – consider
whether this is needed (other steps as well)
CASE 5
Baby P has eczema and is 4 months of age – he is skin prick negative to all major allergens
Mum has got eczema as well and dad suffers from asthma
You know about the LEAP and would like to advise them on weaning and early introduction of nuts
How can the dietitian help you?
Provide weaning advice on introduction of vegetables, fruit, grains
Need 6 g of peanut per week -need to keep it in the diet
Adherence to study protocol was excellent – 92% !Du Toit et al. N Engl J Med
2015;372;9:803-811
CASE 6
• Child with non-IgE mediated CMPA and severe feeding difficulties
• Mealtimes take up to 11/2 hours• Gagging on dual texture – will
have pieces – if self feeding• Mum had to stop working
because of the feeding difficulties
• How can dietitian help you with this?
CASE 6- PREVALENCE IN FOOD ALLERGY
Meyer et al.2013: Study on 437 children with non-IgE mediated food allergies: 30 % of physician documented feeding difficulties as a problem
40.2% of parents perceived feeding difficulties as a problem
Children with feeding difficulties had a higher number of foods eliminated
27
CASE 6- DIETARY MANAGEMENT PRINCIPLES
Manage underlying medical condition
Assess behavioural aspect of feeding and what CAN be addressed
Keep advice simple: Ensure correct feeding equipment
Reduce meal times (< 30 min)
Ensure that distraction is kept to minimal
Mealtime environment is relaxed
Offer manageable portions
Ensure that positive reinforcement occurs
Mealtime routine
Ensure that food choices are not overwhelming
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CASE 6- DIETARY MANAGEMENT PRINCIPLES
Texture hypersensitivity – get SALT involve: Identify the level of sensory hypersensitivity:
- Can child see new food without becoming upset
- Can child tolerate new food on plate
- Does child tolerate smell when somebody is cooking
- Does the child tolerate mess on the hands
- Does the child tolerate mess in the face (especially young toddler)
- If gagging, at what point in the swallowing process?
Identify the predominant sense that is involved (i.e. texture)
Change only 1 aspect of food: keep texture the same and introduce new taste, or change the texture of 1 food but keep taste the same
Offer tips on equipment (speech therapist)
Sensory desensitisation (i.e. messy play ect)
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CONCLUSION
A dietitian is an essential part of allergy services
Part of multi-disciplinary team
Practices at different levels – community and in hospital
Courses exist for dietitians to follow to increase knowledge and competence in food allergy
Many resources exist to support dietitians but resources exist also for HCP that can be downloaded from the BDA site
Dietitian have skills that potentially can reduce time/cost and improve QoL for parents
