food allergy in infancy and beyond

Food allergy in infancy and beyond

A practical management approach

Ruth Charles

Ruth Charles, Paediatric Dietitian. www.nutrikids.ie

Food labelling & the law

• Legislation European Directives 2003/89/EC and 2006/142/EC • Pre packaged foods• All ingredients • Presence of 14 recognised allergens

Cereals containing gluten and products thereofCrustaceans and products thereofEggs and products thereofFish and products thereofMilk and products thereof (including lactose)Nuts i.e. almond, hazelnut, walnut, cashew,pecan nut, brazil nut, pistachio nut, macademia nut, queensland nut and products

Celery and products thereofMustard and products thereofSesame seeds and products thereofSulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10 mg/litre expressed as SO2Lupin and products thereofMolluscs and products thereofSoybeans and products thereofPeanuts and products thereof


2011

Irish Food Allergy Network (IFAN) care pathways for milk, egg, nut & others.In development 2011/2012


Patient Z: first contact

• Summer time• 4 year old girl, only child• Single mum, smoker• Living in caravan in granny’s garden


Patient Z

• Viral RTI’s increased frequency since age 2, onset of wheeze age 3• Rhinitis/hayfever: from age 3

• Active, congested• Sleep affected

• Eczema from 6 weeks of age• Widespread• Actively oozing• Infected• Itchy, waking scratching

• “Miserable”, pale, anorexia• Growth faltering• “RAST” available


Growth


RAST at age 2, repeated age 4

Milk +1 +2Egg +1 +3Peanut +2 +2Soy +2 +3

• Elimination of all these foods and derivatives recommended since age 2.


Food intake

8 am Breakfast:½ Ricekrispies/cornflakes + rice milk½ slice toast and margarineCup of tea11amPlaygroup snack:1 Ricecake & jamCarton juice12.30 Playgroup LunchSent from home or 12 month baby jar. Carton juice.

2pm Playgroup afternoon snackBanana/rice cake. Carton juice4pm Playgroup teaAs at lunch. Carton juice. Home by 6pm Eats crisps/jellies/biscuits. Diluted squash 800ml/day.Bed 9-10pm

Est. 1100kcals, 21g protein


What do you do?


Suggested issues & priorities

Food Allergy

Symptomatic treatment: congestion, rhinitis, itch, infection.

Atopic : “Allergic March”

Plan for management of co-morbidities (including housing/smoking)

Sleep

Growth


http://www.eaaci.net/index.php


“reactions to food can only be diagnosed by a thorough diagnostic procedure, taking into account the patient’s history, the degree of sensitization and the clinical relevance of the sensitization”.


Allergic March

Temporal pattern of progression from eczema to allergic rhinitis and asthma.Ker 2009Mechanisms by which allergen exposure through the epidermis can initiate systemic allergy and predispose individuals to atopic dermatitis, allergic rhinitis, and asthma have become clearer in recent years. Spergel 2010.GI allergic disease


Growth & nutrition issues

Calories

• Appetite• Protein energy

ratio• Dental health• Bowel function

Blood health

• Haem iron• Tannin• B12• Folate

Bone health

• Calcium • Phosphorous• Vitamin D• Magnesium• Oral & topical

steroids


Energy requirements

Approx 300kcal energy deficit for normal growth requirements


Patient Z: effect of atopy on metabolic rate

↑↑Metabolic rate↑Cell

turnover

Infection

Accelerated cell loss

Stress

Catch –up growth

+normal requirements

? Net energy cost ?


Calories & energy

• Consider protein : energy ratio• MUFA/PUFA cold oils added to lunch and dinner• Carbohydrate 6 times a day, portions as tolerated.– Fortified breads– Oat/wheat based cereals– Potatoes/pasta/couscous– Fructose/glucose

• Supplementary FSMP• Address anorexia


Anorexia

• Find & treat cause if possible– Infection– Stress

• Consider GI co-morbidities


GI allergic disease, NICE UK 2011

Consider the possibility of food allergy in children and young peoplewhose symptoms do not respond adequately to treatment for:

atopic eczemagastro-oesophageal reflux diseasechronic gastrointestinal symptoms, including chronic constipation.


Blood health

• Haem iron animal protein source 4 times a week– Beef, lamb, pork

• Non-haem iron sources: fortified cereals consumed at same time as vitamin C source

• Supplement if medically indicated


Bone health

• Supplement until milk tolerance is established• Consider divided dose of calcium• RDA for age


Allergy testing

• RAST unhelpful &unspecificMilk +1 +2Egg +1 +3Peanut +2 +3Soy +2 +3

RAST rating IgE level (KU/L) comment

0 < 0.35ABSENT OR UNDETECTABLE ALLERGEN SPECIFIC IgE

1 0.35 - 0.69LOW LEVEL OF ALLERGEN SPECIFIC IgE

2 0.70 - 3.49MODERATE LEVEL OF ALLERGEN SPECIFIC IgE

3 3.50 - 17.49HIGH LEVEL OF ALLERGEN SPECIFIC IgE

4 17.50 - 49.99VERY HIGH LEVEL OF ALLERGEN SPECIFIC IgE

5 50.0 - 100.00VERY HIGH LEVEL OF ALLERGEN SPECIFIC IgE

6 > 100.00EXTREMELY HIGH LEVEL OF ALLERGEN SPECIFIC IgE


Allergy Testing

• EAACI/NICE/RCPCH:– complementary and alternative medicine (CAM)

allergy tests: applied kinesiology, serum specific IgG, hair analysis and Vega tests have no place in the diagnosis and/or management of food allergy.

• After allergy focused clinical history, serum specific IgE, skin tests, oral food challenges in those trained in their use and competent in their interpretation.


Recommended interpretation of food allergen–specific IgE levels (kUA/L) in the diagnosis of food allergySampson 2000

Egg Milk Peanut Fish Soy Wheat

↓ Probabilityofreaction

Reactive if ≥ (no challenge necessary)

7 15 14 20 65 80

Possibly reactive (physician challenge*)

30† 26†

Unlikely reactive if < (home challenge*)

0.35 0.35 0.35 0.35 0.35 0.35

*In patients with a strongly suggestive history of an IgE-mediated food allergic reaction, food challenges should be performed with physician supervision, regardless of food-specific IgE value. If the food-specific IgE level is less than 0.35

kUA/L and the skin prick test response is negative, the food challenge can be performed at home unless there is a compelling

history of reactivity.


? Food Allergy ?• Prevalence of food allergy in this population is significantly

higher than in the general population. EAACI 2008• Allergy focused clinical history– Ever had severe reaction to food? Describe any

reaction.– Ever eaten milk, egg, nut, soy?– What happens when those foods are eaten?– need if any for testing.

• Address nutrient deficiencies as indicated

• Reintroduce as much food as possible.• Re-evaluate over time.

food allergy in infancy and beyond

Documents

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