marion groetch, ms, rdn director of nutrition services
TRANSCRIPT
Food Allergies
Marion Groetch, MS, RDN
Director of Nutrition Services
Jaffe Food Allergy Institute
Icahn School of Medicine at Mount
Sinai
New York, NY 10029
I have the following financial
relationships to disclose:
Nutricia North America
No products or services produced by this company are relevant to my presentation.
Objectives
Define food allergy
Understand the epidemiology of food allergies
in children
Understand the correlation of food allergies with
nutritional deficiencies
Be able to manage the nutritional challenges
posed by the child with food allergies
Guidelines for the Diagnosis and
Management of FA in the US: NIAID-Sponsored Expert Panel Report
Working with more than 30 professional organizations,
federal agencies and patient advocacy groups led the
development of “best practice” clinical guidelines based
on comprehensive review and objective evaluation of
the recent scientific and clinical literature on FA.
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58
Definition
“An adverse health effect arising from a
specific immune response that occurs
reproducibly on exposure to a given food.”
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58
Adverse Food Reactions
Toxic / Pharmacologic Non-Toxic / Intolerance
Bacterial food poisoning
Heavy metal poisoning
Scombroid fish poisoning
Caffeine
Non-immunologic
Lactase deficiency
Galactosemia
Pancreatic insufficiency
Gallbladder / liver disease
Gustatory rhinitis
Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol 2006;117:S470-475.
Symptoms of Food Allergy
Anaphylaxis
An IgE mediated allergic reaction that is rapid in onset
(minutes to several hours after contact with an allergy
causing substance) and may cause death.
Food allergy is #1 cause of anaphylaxis in the ED
Any food can be responsible but highest risk: peanut, tree nut, seafood
cow’s milk and egg in young children
Eosinophilic
esophagitis
Eosinophilic
gastritis
Eosinophilic
gastroenteritis
Atopic dermatitis
Adverse Food Reactions
IgE-Mediated
(most common)
Non-IgE Mediated
Cell-Mediated
Immunologic
Systemic
Oral Allergy Syndrome
Immediate gastrointestinal allergy
Asthma/rhinitis
Urticaria
Morbilliform rashes and flushing
Contact urticaria
Protein-Induced
Enterocolitis
Protein-Induced
Enteropathy
Eosinophilic proctitis
Dermatitis
herpetiformis
Contact dermatitis
Sampson H. J Allergy Clin Immunol 2004;113:805-9, Chapman J et al. Ann
Allergy Asthma & Immunol 2006;96:S51-68.
Proctocolitis
(non-IgE mediated)
Symptoms- gross or occult blood in the stools
Generally presents in first few months of life to
milk/soy formula or food proteins passed through
maternal milk
Usually resolves around by 1 year of age.
Food Protein Induced Enterocolitis
(non-IgE mediated)
FPIES is generally seen before 3 months of age
Acute- Profuse vomiting, diarrhea and lethargy beginning 1-3 hours after ingestion of offending food (usually milk or soy but other foods have been implicated including rice, oat, poultry, legumes, fruits and vegetables)
Chronic- chronic vomiting and diarrhea, FTT, hypoalbuminemia
Clinical tolerance usually develops by 3 years
Symptoms can be severe enough to cause dehydration and shock (20%)
www.iaffpe.org
FPIES Nutritional Risk
Poor growth at presentation
Negative infant experience with foods,
reinforcing poor intake
Long-term/multiple food elimination diets
Solid-food FPIES resulting in delayed
introduction of foods
Poor feeding skill acquisition and nutrient intake
Eosinophilic Esophagitis (EoE)
(mixed IgE and non-IgE)
Chronic, immune/antigen-mediated esophageal
disease characterized by
Clinically: symptoms related to esophageal dysfunction
Histologically: eosinophil-predominant inflammation
www.apfed.org
Liacouras et al, J Allergy Clin Immunol 2011
EoE Nutritional Risks
Clinical symptoms: Nausea/vomiting, Regurgitation, Chest pain,
Feeding difficulties and food refusal, Delayed growth, Early satiety,
Abdominal pain, Dysphagia with solid foods more common in
adolescents and adult
Poor dietary intake due to persistent symptoms
Poor growth despite adequate intake
Multiple food elimination diets for extended
periods of time
Poor compliance with elimination diet
Disorders Not Proven to be
Related to Food Allergy
Migraines
Behavioral / Developmental disorders
Arthritis
Seizures
Inflammatory bowel disease
Epidemiology
Self-perceived adverse reaction rates exceed rates based on OFC
Studies suggest a cumulative prevalence of 3% to 6% in children
The inclusion of mild reactions to fruits and vegetables could
result in calculation of prevalence exceeding 10% in some
regions.
There are data from numerous studies to suggest an increase in
prevalence.
Prevalence varies by age, geographic location, and possibly
race/ethnicity.
Many childhood food allergies resolve.
Goal of Dietary Management
To prevent acute and chronic food allergic
reactions, while maintaining appropriate
nutrition for growth and development.
Dietitian’s Focus
Effective avoidance
Daily Living with FA
Nutritional adequacy
Label Reading
Read the entire product label
each and every time an item is purchased.
Label Reading
Food Allergen Labeling Consumer
Protection Act (FALCPA) Milk
Egg
Wheat
Soy
Peanut
Tree nut*
Fish*
Crustacean shellfish*
*Specific species must be listed
Incidental Ingredients
A “major food allergen” may not be omitted
from the product label even if it is only a
minor ingredient
Allergens not considered “major” may remain
unidentified on product labels
Cross-Contact
Cross contact occurs when safe foods come
in contact with an allergen, causing the safe
food to contain small amounts of unintentional allergenic ingredients.
Cross contact
Precautionary labeling such as
May contain…
Manufactured in a facility…
Manufactured on shared equipment…
Voluntary and unregulated
Food Allergy Guidelines
The expert panel suggests
avoiding any product that
has an advisory statement
for your allergen.
There is no evidence that
strict avoidance has any
impact on the rate of
natural remission to a
specific food allergen
To Avoid or Not to Avoid
Cross reactivity
Sicherer
JACI
2003;108(6):881-
90
Daily Living with Food Allergies
Shopping
Cooking
Eating in restaurants or friend’s homes
Traveling
Going to school and camp
Nutrition
www.cofargroup.org
click on Food Allergy Education Program
Children with multiple food allergies
or cow’s milk allergy are at increased
risk of…
Macronutrient/Micronutrient deficiencies or imbalance
Shorter stature
Failure to thrive
Nutritional Rickets/kwashiork or/marasmus
Christie L, et al. J Am Diet Assoc. 2002;102:1648–1651.
Henriksen C, et al. Acta Paediatr. 2000;89:272–278.
Isolauri E, et al. J Pediatr. 1998;132:1004–1009.
Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569.
Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499.
Noimark, Cox. PAI 2008; 19:188-195.
Flammarion et al. Pediatr Allergy Immunol. 2011; 22: 161-165.
Indication of Increased Nutritional Risk
Signs or symptoms of nutritional deficiencies (e.g., poor growth, iron
deficiency anemia)
Greater number or nutritional value of eliminated foods
Greater reliance on or dietary intake of food(s) to be eliminated
Picky or self-selective eater
Delayed introduction of solid complementary foods
Poor variety or volume of foods provided/accepted
Feeding delay/difficulties
Unwillingness of child to ingest supplemental formula or enriched beverage
Environmental or psychosocial factors limiting ability to provide nutritionally
complete diet
Medical or psychological diagnosis affecting dietary intake
Is poor growth strictly a
nutritional issue?
Cross sectional study comparing children with food
allergies (n=96) who had been counseled by a dietitian
to paired controls without food allergies (n=95).
Children with food allergies had weights and heights
within the normal range; however, they were smaller for
their age than the non-allergic controls, even when they
received similar nutrition.
Flammarion S, Santos C, Guimber D, Jouannic L, Thumerelle C, Gottrand F, et al.
Diet and nutritional status of children with food allergies. Pediatr Allergy Immunol 2011 Mar;22(2):161-165
Common FA in Children
Milk
Egg
Soy
Peanut
Wheat
DRACMA
Treatment of CMA in Infancy
A cow’s milk substitute of adequate nutritional value is necessary
until 2 years of age to meet nutritional requirements:
Breast milk
Maternal CM protein avoidance
Maternal calcium supplement
Substitute formula
Fiocchi, Brozek, Schuenemann, et al. WHO Diagnosis and
Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. April 2010.
Hypoallergenic Formulas
Extensively Hydrolyzed Casein Formulas (MW< 3000Da)
Amino Acid- based Formulas- peptide free formulas
Partially Hydrolyzed formulas are not hypoallergenic
AAPCON. Hypoallergenic infant formulas. Pediatrics, 2000, 106, 2 Pt 1, 346-349
Substitute formula
Symptoms or
allergic disorder
1st formula recommendation
2nd formula recommendation
3rd formula recommendation
IgE
low risk of
anaphylaxis
Extensively
hydrolyzed
Amino acid
based
Soy
IgE
high risk of
anaphylaxis
Amino acid
based
Extensively
hydrolyzed
Soy
Non-IgE
FPIES*/
proctocolitis
Extensively
hydrolyzed
Amino acid
based
-------
EoE Amino acid
based
------- -------
*Food protein-induced enterocolitis syndrome
Fiocchi A, Schunemann HJ, Brozek J, et al. Diagnosis and rationale for action against cow's milk allergy (DRACMA): A summary
report. J Allergy Clin Immunol. 2010;126:1119-28.
Comparison of Cow’s Milk (CM) substitutes
CM or
CM subs.
KCAL/
8 oz
PRO g FAT g Ca mg/
Vit.D IU
CM 150 8 8 300 / 100
Soy enriched 100 7 4 350 / 100
Oat enriched 120 4 3 300 / 100
Hemp enriched 100 2-4 6 400 / 80
Rice enriched 120 1 2.5 300 / 100
Almond enriched
50 1 2.5 300 / 100
Baked milk inclusion
Baked-Milk study
~ 75% of milk-allergic children tolerate H-DM & ingestion
immunologic changes consistent with immunotherapy
Accelerates tolerance (16-fold vs avoidance)
Baked-Egg study
~75% of egg-allergic children tolerate of H-DE & ingestion
immunologic changes consistent with immunotherapy
Accelerates tolerance (15-fold vs avoidance)
Nowak-Wegrzyn, Groetch. Let them eat cake. Ann Allergy Asthma Immunol 109 (2012) 287–288
Wheat Avoidance
4 servings of enriched and whole grains provides 50%
of the RDA for CHO, iron, thiamin, riboflavin and
niacin for children>1 yr and also a significant source of
B6 and manganese and Folate.
Alternative Grains
Rice
Corn
Oat
Rye
Barley
Buckwheat
Amaranth
Quinoa
Millet
Homologous Grain Proteins
20% of those with wheat allergy may be
clinically reactive to another grain.
*Use of alternative grains should be
individualized and based on tolerance as
determined by the allergist.
Sicherer SH. Clinical implications of cross-reactive food allergens. JACI 2001 Dec;108(6):881-90.
Differences in management of wheat
allergy and Celiac Disease
Celiac- Autoimmune disorder caused by gluten sensitivity
Strict, lifelong avoidance of wheat, rye and barley
All non-gluten grains allowed: Amaranth, arrowroot, buckwheat, corn, legume flours, millet, Montina, nut flours, rice, potato flours or starch, sorghum ,tapioca, teff, quinoa
Pure uncontaminated oats- most organizations allow moderate amounts of gluten free oats
Egg/Soy/Peanut
Generally, does not have as great a nutritional
impact
Greater concern if MFA or if dietary patterns
(vegetarian) or nutritional cofactors
Summary
Food allergies are a serious public health concern now
estimated to affect more than 12 million Americans.
The cornerstone of food allergy management is
avoidance of the identified allergen.
Allergen elimination diets can significantly affect quality
of life and are not without nutritional risk.
Patients require expert guidance to learn how to
identify their allergen(s) in our vast food supply and
meet their nutritional needs within the context of the
elimination diet.