a simple case of cow’s milk allergy?€¦ · product label even if it is only a minor ingredient...
TRANSCRIPT
A simple case of cow’s milk allergy?
Carina Venter PhD RD Brian P Vickery MD
Disclosure Brian Vickery
• Employment: Pediatric Institute of Emory University + Children’s Healthcare of Atlanta
• Consultant/Advisor: Aimmune Therapeutics; AllerGenis, LLC; Food Allergy Research and Education (FARE); Reacta Biosciences
• Grant support: NIH-NIAID; FARE; Genentech • Clinical investigator: Aimmune; DBV Technologies; Regeneron • Equity interests/stock ownership: none
2
Disclosure Carina Venter
• Provided and reviewed education material for: • Danone • Abbott • Reckitt Benckiser Group • DBV technologies • Research support • Reckitt Benckiser Group
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Objectives
• Describe the process involved in the diagnosis the different presentations of cow’s milk allergy in early childhood
• Develop increased knowledge on formula choice and dietary management of cow’s milk allergy
• Be able to advise parents on suitable treatment options for tolerance development
4
Different presentations of cow’s milk allergy Cow’s milk
allergies
IgE mediated cows milk allergies
Non-IgE mediated cow’s milk allergies
Food Protein induced enterocolitis
Other forms of non-IgE mediated cow’s milk allergies
Eosinophilic Esophagitis
Mild to moderate non-IgE mediate cow’s milk llergy
Cow’s milk allergy is the most complex presentation of food allergy in early childhood
Trevor Brown
Different presentations of cow’s milk allergy Cow’s milk
allergies
IgE mediated cows milk allergies
Non-IgE mediated cow’s milk allergies
Food Protein induced enterocolitis
Other forms of non-IgE mediated cow’s milk allergies
Eosinophilic Esophagitis
Mild to moderate non-IgE mediate cow’s milk llergy
Dietary management
Diagnosis • History • Testing if applicable • Food elimination followed by
Food reintroduction/trial or “challenge” phase
Management phase
IgE mediated cow’s milk allergies
History • Dietary focused allergy history • Symptoms within 2 hours of
consumption • Foods 14 major allergens
Skypala et al. Clin Exp Allergy 2015
Children’s Healthcare of Atlanta | Emory University
Food Allergy Evaluation: History Is Critical; Ask Specific Questions
• Suspected culprit food protein (i.e., egg vs. red Gatorade): – Which was it? One of the “big 8?” – What form did they eat? Had they eaten it before? – How much? – Have they eaten it again - ask about other forms - since the episode?
• What happened then? – Timing & sequence of symptoms?
• Yes: Hives, swelling, abd pain, vomiting, wheezing/coughing, significant AD flare, anaphylaxis within 15 – 60 (up to 120) min
• No: headaches, fatigue, flat nonpruritic red rash on face or bottom; significant delay between exposure & sx
– Did the episode require treatment?
Children’s Healthcare of Atlanta | Emory University
What about a young child who has never eaten the food?
What if the patient has atopic dermatitis?
Children’s Healthcare of Atlanta | Emory University
Decision Points
Sampson HA Allergy 2005 (60): 19-24
*** These numbers predict likelihood of symptoms, not severity, and were studied in patients with a high pretest probability of disease ***
Note: not Class IV
Children’s Healthcare of Atlanta | Emory University
Diagnostic Limitations
• Most direct-to-consumer testing is worthless • Conventional tests are often misinterpreted • Correctly interpreted tests still have significant limitations:
– probabilistic, not diagnostic – cannot determine alone if patient is allergic or tolerant – cannot determine how much food it might take to react – cannot tell “severity” / offer assessment risk
• Every patient is thus assumed to be at high risk for a life-threatening reaction – Important downstream effects for families, communities, schools, etc.
Chafen JJ et al JAMA 2010
Children’s Healthcare of Atlanta | Emory University
Key Diagnostic Points
1. Skin & blood tests are only markers of exposure, not disease (TB) 2. A convincing history of symptoms after ingestion is key
– If the child can eat the food sometimes, allergy is not likely
3. If a prick skin test, done correctly, is negative, allergy is not likely – NPV > 90%
4. In general, strongly positive tests might be helpful – Prick test > 8-10 mm or IgE level above “decision point”
5. Indeterminate test results are common and can be confusing, especially in certain settings (e.g., AD, no/poor history)
6. If uncertain, the gold standard for diagnosis is oral challenge
Case 1
• Case scenario: Emily • You are seeing a 6-month old girl who had an infant cereal containing
milk, which her day care attendant gave to her • She developed wide-spread urticaria, breathing difficulties,
angioedema and was rushed to the ER (A&E). • Mother still breast feeding, has not given Emily any milk containing
food, but mother has been consuming milk containing food while breast feeding and Emily has not had any problems
History
• Breast fed with maternal consumption of cow’s milk: Ice cream, yogurt, cheese, cake, cookies, butter
• Not tried infant formula • Eaten some fruit and
vegetable purees • Eaten baby rice • Not tried yogurt • Infant cereal:
SPT results as follow:
• Histamine 4 mm
• Saline 0 mm
• Milk 8 mm
Do you think she has a cow’s milk allergy?
• Yes • No • Need further testing: Specific IgE tests • Need further testing: component resolved diagnostic testing
Allergy testing should only be carried out if there is clinical suspicion of cow's milk allergy as it has poor predictive value as a screening tool. Luyt et al. Clin Exp Allergy 2014
Specific IgE results
• Milk specific IgE 12 kuA/L • Milk specific casein 10 kuA/L • Milk specific beta-lactaglobulin 6 kUA/L
Mukkada 2010; Furuta 2018 18
Are you going to perform a food challenge?
• No • Yes to cow’s milk • Yes to baked milk
Can babies react to cow’s milk allergens via breastmilk? 1. No
2. Yes
3. Depends on the type of cow’s milk allergy
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Symptoms while breastfeeding
Rationale and substantiation: • Host et al. 1988:
• Only 1 prospective study • 0.5% presented while on breast milk only (out of 2.2%)
• Some infants with CMA can react to residual β-lactoglobulin transferring to breast milk Breast milk: 0.9-150ug/l (median 4.2ug/l) EHFs: 0.84 -14.5ug/l
• However limited evidence available to substantiate this as first line formula if breast milk not available
Breast milk is the preferred nutrition for infants with CMA - Infant should continue taking breast milk while, if advised, mom avoids dairy under medical supervision
1. Host, et al. Acta Paediatr Scand. 1988;77:663-70. 2. Host, et al. Allergy. 2004; 59: 45–52. 3. Makinen-Kiljunen, et al. Clin Exp Allergy. 1993;23:287–91. 4. Rosendal, et al. J Dairy Sci. 2000;83:2200–10. 5. Meyer, et al. J Allergy Clin Immunol Pract. 2018;6:383-99. 6. Koletzko, et al. J Pediatr Gastroenterol Nutr. 2012;55:221-9. 7. Ludman, et al. BMJ. 2013;347:f5424. 8. Venter, et al. Clin Transl Allergy. 2013;3:23.
The spectrum of cow’s milk based formulas
1. https://www.seas.upenn.edu/~cis535/Fall2004/HW/GCB535HW6b.pdf. July 3, 2018. 2. American Academy of Pediatrics Committee on Nutrition. Pediatrics. 2000;106:346-9. 3. Lowe, et al. Expert Rev Clin Immunol. 2013;9:31-41. 4. Hongsprabhas, et al. Joint ACS AGFD-ACS ICSCT Symposium; 2014.
Formula type: Amino acid- based (AAF)
Extensively hydrolyzed
(eHF)
Partially hydrolyzed Regular (Intact protein)
Protein source
100% free amino acids
Cow milk Cow milk Cow milk
Peptide size, kilodaltons
N/A (free AAs ~0.121)
Most <1.52
Up to 5% >3.53
Dairy: Most <53 Dairy: 14-673
Soy: 20-2254
Presentation or condition
NIAID US guidelines
DRACMA international guidelines
ESPGHAN European guidelines
BSACI guidelines
Breast-feeding with ongoing symptoms (already on maternal elimination diet) or requiring formula, e.g. to supplement
EHF or AAF “Prior to initiating an oral food challenge… until the allergic [sic]
food is identified”
Not specified EHF or AAF
“In breast-fed infants with severe symptoms …it is common
practice in many countries to use AAF for diagnostic elimination...”
AAF if symptoms when
exclusively breastfed
Symptoms while breastfeeding
Limited data suggest an AAF can be used first line if formula is needed to supplement or replace breast milk because intolerance to eHF may occur
First choices for CMA and related conditions ONLY when formula is needed
1. Meyer, et al. J Allergy Clin Immunol Pract. 2018;6:383-99. 2. Boyce, et al. Nutr Res. 2011;31:61-75. 3. Koletzko, et al. J Pediatr Gastroenterol Nutr. 2012;55:221-9. 4. Luyt, et al. Clin Exp Allergy. 2014;44. 5. Ludman, et al. BMJ. 2013;347:f5424. 6. Venter, et al. Clin Transl Allergy. 2013;3:23. 7. Fiocchi, et al. Pediatr Allergy Immunol. 2010;21 Suppl 21:1-125. Hill, et al. Clin Exp Allergy. 2007;37:808-22. 8. de Boissieu, et al. J Pediatr. 1997;131:744-7. 9. Host, et al. Allergy. 2004;59 Suppl 78:45-52.
Other information
• Label reading
• Foods to avoid
• Substitute foods
• Weaning advice: Flavor, texture, variety
• Nutritional adequacy of diet
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
Front of package labeling not useful
• “Dairy free” no definition • “Non-dairy” defined but allows casein • MUST READ ingredient list and contains statement
https://farrp.unl.edu/resources/gi-fas/opinion-and-summaries/dairy-free-and-non-dairy
Allergens can be listed in the ingredient list
Allergens can be listed in the “contains” statement
Flour (wheat), sugar, milk, egg, natural flavor (soy)
Flour, sugar, milk, egg, natural flavor Contains: wheat, milk, egg, soy
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Cross contact
• Precautionary Allergen labeling (PAL) • May contain… • Manufactured in a facility… • Manufactured on shared equipment…
VOLUNTARY AND UNREGULATED
IF it is NOT there does not mean it is definitely safe/not contaminated
Remington BC, et al. Food and chemical toxicology. 2013
Ford et al. 2010
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Who should avoid
products with PAL?
• Patients with FPIES? • Not typically
• Patients with EoE?
• Maybe
• Patients tolerating baked milk or baked egg? • Depends on the product
• Patients with high threshold?
• Not easy to define
FALCPA Exempts
• Foods that are placed in a wrapper or container or prepared on a made-to-order basis
• FALCPA does not cover foods “served in restaurants or other establishments in which food is served for immediate human consumption”.
• Alcoholic beverages, medications, anything regulated by the USDA (fresh meat, poultry, eggs fruits and vegetables).
FALCPA exemptions
• Are there any other areas not covered by FALCPA?
• Yes, there are quite a few areas where the law does not apply:
• · Prescription drugs • · Over-the-counter drugs • · Personal care items such as cosmetics, shampoo, mouthwash, toothpaste or
shaving cream. • · Any food product regulated by the USDA, which includes meat, poultry, or
certain egg products. • · Any product regulated by the Alcohol, Tobacco Tax and Trade Bureau (ATTB).
This includes alcoholic drinks, spirits, beer and tobacco products. • · Any restaurant foods or foods that are placed in a wrapper or container in
response to a person's order for that food. This includes street vendors, festival foods, fast food restaurants.
• · Kosher labeling • · Pet: foods, supplements, and supplies
• • More information on FALCPA: https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm106890.htm •
Milk Oral Immunotherapy – 5 RCTs
Taniuchi et al Hum Vaccin Immunother 2017
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Nowak-Wegrzyn. JACI In Pract. 2018
36
Nowak-Wegrzyn. JACI In Pract. 2018
If baked milk tolerant: How much baked milk • Know exactly how much milk the patient has tolerated • THEN you can provide specific guidance For instance published recipes provide • No more than 1/6th cup of milk per serving (1.3 g protein)
• For example: I cup of milk in a recipe that yields 6 servings
Leonard, Caubet, Kim, Groetch, Nowak-Wegrzyn. JACI In Pract. 2015
Caution: Read Product labels carefully
1. Rule: Milk or egg ingredient is the 3rd ingredient or further down the list of ingredients. Although there is no way to critically evaluate this practice, it has been used effectively.
2. Final cooking time will depend on the size of the finished product- most published reports suggest 30 min for 350 degrees
3. All baked products must be baked throughout and not wet or soggy in the middle.
Leonard et al. 2015
Non-IgE mediated cow’s milk allergy
Food protein induced enterocolitis syndrome
History
• The NIAID Food Allergy Guidelines recommend using the medical history and OFC to establish a diagnosis of FPIES
• When history indicates that infants or children have experienced hypotensive episodes or multiple reactions to the same food, a diagnosis may be based on a convincing history and absence of symptoms when the causative food is eliminated from the diet.
• Boyce et al. Journal Allergy Clin Immunology 2010 • Nowak-Wegrzyn et al. Journal Allergy Clin Immunology 2017
Skin prick tests/Specific
IgE tests
• Food-specific IgE and skin prick testing may be performed to provide complete evaluation for food sensitization, particularly when considering a food challenge.
• Consider food-specific IgE and skin prick testing in children with FPIES as a positive test can infer a greater chance of persistent disease.
• Boyce et al. Journal Allergy Clin Immunology 2010 • Nowak-Wegrzyn et al. Journal Allergy Clin Immunology 2017
Case 2: Jennifer
• Breastfed infant just starting solid foods
• At 5 months of age, had first episode of repetitive, non-bloody, non-bilious vomiting followed by diarrhea and lethargy after 4th day of rice cereal mixed with cow’s milk formula
• Mother suspected GI illness and treated with rehydration fluids and Jennifer improved
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Jennifer
• Two days later, rice cereal was offered again (mixed with cow’s milk formula) with a recurrence of symptoms 2 hours later
• This time they went to the emergency department and intravenous fluids were given and mom tells the doctor that she suspects the rice cereal
• They were referred to the allergy clinic
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Jennifer – Diagnosis
History - Currently eating apple, banana - Quinoa, baby rice
- Reaction: Baby rice WITH standard
infant formula on 2 occasions
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Perform any testing?
• Yes (required to diagnose FPIES)
• No – never
• Yes (to investigate co-morbid sensitization)
Perform a food challenge?
• Yes • No • Yes – to baked milk
When do you challenge for FPIES?
• OFC every 18-24 months in patients who have not had a recent reaction.
• Protracted vomiting and dehydration necessitate fluid resuscitation in approximately 50% of reactive challenges.
• Considered high-risk and should be conduction in a setting with IV access.
• May consider challenge to high-risk foods never ingested in the office
49
• Jarvinen et al. Journal of All Clin Immunol in practice. 2013 • Nowak-Wegrzyn et al.. Journal of All Clin Immunol 2009.
Maternal avoidance of cow’s milk?
Mukkada 2010; Furuta 2018 50
YES NO
1
Formula choice – ONLY IF NEEDED
Meyer, et al. 2018; Fiocchi, et al. 2010; Koletzko, et al. 2012; Luyt, et al. 2014; . Boyce, et al. 2011
Clinical presentation DRACMA BSACI Guidelines NIAID US Guidelines ESPGHAN
Anaphylaxis AAF AAF No specific recommendation AAF
Acute urticaria or angioedema EHF EHF No specific recommendation EHF
Atopic eczema/dermatitis EHF EHF No specific recommendation EHF
Eosinophilic Esophagitis AAF AAF
The NIAID guidelines acknowledge that trials in EoE have shown symptom relief and endoscopic improvement in almost all children on AAF/elemental diet, though no specific recommendation on formula choice is made.
AAF (as specified by current ESPGHAN guidelines on EoE)
Gastroesophageal reflux disease EHF EHF No specific recommendation EHF
Cow’s milk protein-induced enteropathy EHF EHF unless severe in which case AAF No specific recommendation EHF but AAF if complicated by faltering growth
FPIES EHF AAF Hypoallergenic formulas are recommended.
EHF
Proctocolitis EHF EHF No specific recommendation EHF
Breast feeding with ongoing symptoms (already on maternal elimination diet) or requiring a top-up‡ formula
No recommendation AAF
No specific recommendation With severe symptoms that are complicated by growth faltering a
hypoallergenic formula up to 2 weeks may be warranted. In many
countries, AAF is used for diagnostic elimination in extremely sick
exclusively breast-fed infants. Although this is not evidence based,
it is aimed at stabilizing symptoms.
Indications that a child is more likely to require and amino acid based formula
symptoms not fully resolved on EHF
faltering growth/failure to thrive
multiple food eliminations
severe complex gastrointestinal food allergies
eosinophilic esophagitis
severe eczema
53 Meyer et al. 2017
Structured Visits
• Burden awareness is key
• Assess QOL, history and trajectory- utilize ancillary staff
• Discuss previous recommendations: “What has and what has not worked?”
• Ask questions: “Are you having a difficult time feeding your child?”
• Lifestyle competency
• Evaluate short and long term goals
• Informed decision: Educate and provide options
• Division of responsibility
• Assess readiness and make appropriate referrals for practical management obstacles
• Utilize available resources: www.fpies.org, Guideline Pocket Guide
• Slide courtesy of Fallon Matney, IFPIES.org
Co-existing food allergies
Nowak-Wegrzyn et al. 2016 55
FPIES foods and their importance in the diet Food Nutrients
Grains Carbohydrate, fiber, thiamine, riboflavin, niacin, calcium, iron, folate, calcium, phosphorous, potassium, pantothenic acid
Poultry Protein, fat, selenium, phosphorous, potassium, zinc, Iron, vitamin B6, Niacin, B12
Legumes Folic acid, Pantothenic acid, Niacin, Thiamine, Pyridoxine, Ascorbic Acid, Vitamin K, Vitamin A, Calcium, Iron, Copper, Zinc and Manganese
Sweet potato
Vitamin A, Pantothenic acid, thiamin, niacin, riboflavin, magnesium, manganese, and potassium
Milk Protein, carbohydrate, fat, vitamin A, vitamin D, riboflavin, pantothenic acid, vitamin B12, calcium, magnesium, phosphate
Soy Protein, Thiamine, riboflavin, pyridoxine, folate, calcium, phosphorus, magnesium, iron, zinc, protein, fiber
Egg Protein, Riboflavin, biotin, protein, vitamin A, vitamin B12, vitamin D, vitamin E, pantothenic acid, selenium, iodine, folate
Venter and Groetch 2014; Raquel Durban
Nutritional considerations
What I do?
• Provide guidance during the introduction of complementary foods – give a list of foods
• Monitor growth (weight and height/length)
• No need to avoid products with precautionary allergen labeling in patients with FPIES
• Textures and chewing: Recommend foods that prevent all levels of feeding dysfunction
Comparison of Cow’s Milk (CM) substitutes- many do not provide adequate nutrition (low protein and fat). Choose carefully and consider patient age!
Cow milk or enriched substitute
KCAL/ 8 oz
Protein g Fat g Calcium mg/ Vitamin D IU
Cow’s Milk 150 8 8 350/100
Soy 100 7 4 300-450/100
Pea Protein 100 8 4.5 450/120
Oat 120 4 3 300/100
Rice 120 1 2.5 300/100
Coconut 80 0 4.5 100-450/100
Almond 50 1 2.5 300-450/100 58
Choose calcium and vitamin D
fortified!
Slide: Marion Groetch 59
Lower risk Moderate risk Higher risk Vegetables
Broccoli, cauliflower, parsnip, turnip, pumpkin
Squash, carrot, white potato, green bean (legume)
Sweet potato, green pea (legume)
Fruits Blueberries, strawberries, plum, watermelon, peach
Apple, pear, orange Banana
High iron foods Lamb, fortified quinoa cereal, millet
Beef, fortified grits and corn cereal, wheat (whole wheat and fortified), fortified barley cereal
Fortified, infant rice and oat cereals.
Other Tree nuts and seed butters* (sesame, sunflower, etc.) *Thinned with water or infant puree to prevent choking
Peanut, other legumes (other than green pea)
Milk, soy, poultry, egg, fish
Mild to moderate Non-IgE mediated cow’s milk allergy
Fox et al. Clin Translation Allergy 2019
61
IMAP guidelines
Fox et al. 2019
62
Case 4
• 3 month old infant
• Reflux does not resolve on thickening milk
• Eczema not responding to topical treatment
• No-one sleeps
History
• https://www.allergyuk.org/health-professionals/mapguideline
Fox et al. 2019
65
TESTING
How will cow’s milk be introduced upon symptom resolution? 1. If breast feed – just reintroduce all milk containing food back into
diet 2. If formula feeding – carefully increase formula milk intake 3. Do the milk ladder 4. 1 and 2
Reintroduction of Cow’s Milk to Confirm Diagnosis
https://www.allergyuk.org/health-professionals/mapguideline
After 6 – 9 months of milk avoidance, how will cow’s milk be introduced into the diet? 1. If breast feed – just reintroduce all milk containing food back into
diet 2. If formula feeding – carefully increase formula milk intake 3. Do the milk ladder 4. 1 and 2
Changes to the Milk Ladder
Eosinophilic Esophagitis I DON’T THINK WE NEED TO DO EOE – I AM DOING THE EOE TALK THE DAY BEFORE
Eve is a 28-month-old female with EoE • Medical history: EoE on diet therapy excluding milk (empiric) and
eggs, peanut, almond and barley (test directed). • Dietary history: Parents are concerned because Eve eats a very
small volume of food. • Supplements: Poly Vi Fluor (400 IU D), • L'il Critter gummies calcium and D (200 mg calcium and 200 IU
vitamin D) • L'il Critters Vitamin C (126 mg vitamin C and 200 IU D and 3 mg zinc)
with Echinacea.
71
Growth
• Growth history: Growth from birth has been following closely around the 25th percentile.
• She has recently had a weight loss of 1.4 pounds (from 23-24 months of age) and there has been no follow up weight check since this time. Weight now dropped to the 3rd percentile.
• Eve was not present so weight/height could not be documented. Mukkada 2010; Furuta 2018 72
Food intake Foods currently in diet: • Meat: Chicken, turkey, beef and pork • Vegetable: Carrot, cucumber, lettuce, olive, onion, squash, tomato
and white potato • Fruit: Apple, banana, cantaloupe, grape, lemon, mango, orange,
pear, pineapple, raspberry and watermelon • Grain: Wheat, rice, corn, oat (Apple Jacks Cereal) • Other: Soy, cod fish
73
Snacks
• Snack-food is provided on demand; parents report Eve is constantly asking for foods (as she is hungry)
• Few actual meals - mostly salty (pretzels, veggie sticks) and sweet snacks (crackers, sweetened dry cereal snacks, fruit snacks, fruit, fruit punch) and an occasional slice of bologna or chicken nugget or 1/4 hotdog
74
Should we add a commercial milk/beverage or formula?
1. No need; use commercial milks 2. Extensively hydrolyzed formula 3. Amino acid based formula
Mukkada 2010; Furuta 2018 75
Growth and EoE – mainly elemental formulas
76
Study Growth outcome
Kelly et al. 1995 ‘…poor weight gain had resolved’
Al-Hussaini et al. 2013 Corrected growth after 2 months of therapy
Liacouras et al. 2005 ‘…no significant weight loss’, ‘or alteration of growth parameters (height, weight, head circumference)’ in those on dietary therapy, however reported that n=5 patients considered to have failure to thrive had a significant increase in weight after receiving AAF
Kagalwalla et al. 2005 Children with failure to thrive on AAF (n=14) mean weight gain was 1.03kg (range 0.1-2.1kg), and of children identified with failure to thrive on the EED (n=5), mean weight gain was 1.32kg (range 0.9-2kg), after six weeks of intervention
Colson et al. 2014 (n=59) diet height and weight gains were significant after 5 months, but weight-for-height z-scores did not change.
Atwal et a. 2019
Extensively hydrolyzed formula vs. Amino acid based formula
Mukkada 2010; Furuta 2018 77
Comparison of Cow’s Milk (CM) substitutes- many do not provide adequate nutrition (low protein and fat). Choose carefully and consider patient age!
Cow milk or enriched substitute
KCAL/ 8 oz
Protein g Fat g Calcium mg/ Vitamin D IU
Cow’s Milk 150 8 8 350/100
Soy 100 7 4 300-450/100
Pea Protein 100 8 4.5 450/120
Oat 120 4 3 300/100
Rice 120 1 2.5 300/100
Coconut 80 0 4.5 100-450/100
Almond 50 1 2.5 300-450/100 78
Choose calcium and vitamin D
fortified!
Should we add a formula?
1. No need; use commercial milks 2. Extensively hydrolyzed formula 3. Amino acid based formula
Mukkada 2010; Furuta 2018 79
Follow-up
• The follow up endoscopy was improved but Eve still has some occasionally regurgitation/vomiting and she had 34 eos/hpf in the proximal esophagus.
• The family opted for further dietary restriction and wheat and soy were also removed.
80
What to advise parents about “precautionary advisory labelling? 1. Exclude these foods from her diet 1. These foods can be allowed
Mukkada 2010; Furuta 2018 81
82
Avoiding precautionary advisory labelling?
Cianferoni et al. 2019
Molina-Infante 2017 Spain Adults
Molina-Infante 2014 Spain Adults Lucendo 2012 Kagalwalla 2017
USA Pediatric CEGIR study 2019
Milk All dairy products (either goat’s or sheep’s milk can cross-react with cow’s milk) Mammalian milk Milk Milk Milk
Egg Egg Egg Egg Egg Egg
Wheat All gluten-containing grains (cross-reactive with wheat, including barley, rye, and oats)
Wheat/gluten-containing grains Cereals (wheat, rice, corn) Wheat Wheat
Soy Legumes, including soy, lentils, chickpeas, peas, beans, and peanuts
Soy/legumes Legumes/peanuts, and soy Soy Soy
Nuts All kind of nuts NA Nuts NA NA
Seafood Fish and seafood NA Fish/seafood NA NA
Other allergens?
Food allergens known to cause oral allergy syndrome symptoms were avoided already by patients before enrollment
No mention No mention No mention NA
May contain
Patients were also advised to avoid processed foods because of the high likelihood of containing wheat or milk traces, including processed meats (eg, sausages and hamburgers), soups, sauces, pizza, mashed potato, and instant rice
No mention No mention No mention NA
Discussion points
What recommendations would you make to help Eve’s parents manage this elimination diet? What recommendations would you make regarding follow-up endoscopy? Would you try more foods? How often?
Mukkada 2010; Furuta 2018 83
84
Food Group Daily Servings Suggested Foods Grains (no wheat)
Select breads, cereals, pastas, crackers, and baked goods made with allowable grains/grain substitutes: Amaranth; arrowroot; barley; black, white, fava, and garbanzo beans; buckwheat; corn; millet; oats (gluten-free); potato (white or sweet); quinoa; rice; rye; tapioca Gluten-free foods are typically wheat-free. Verify foods are also soy, milk, nut, and egg-free.
Protein Foods (no eggs, fish, nuts)
Eat a variety of protein foods (no eggs, fish/shellfish, or peanuts/tree nuts) each week. Select chicken/turkey, pork loin, and lean beef.
Milk Alternative† (no soy)
Coconut, hemp, or rice milk Coconut or hemp yogurts Pea protein or rice cheeses Coconut ice creams Elemental formula: Elecare® Vanilla, Neocate® Jr, Alfamino® Jr
Vegetables
Aim to eat a variety of colors daily. Include dark green, red, orange, and other vegetables (e.g., spinach, broccoli, beets, tomato, carrots, squash, sweet potato, beans (no soy), and peas) and vegetable juice.
Fruits
Aim to eat a variety of fruits daily (e.g., apples, oranges, peaches, bananas, melons, berries, pears, pineapples, plums). Choose whole fruits more often than fruit juice.
Oils
Canola, olive, safflower, sunflower, vegetable Milk and soy-free margarine Milk, soy, and egg-free salad dressings
Food reintroduction
85
1st Food • Consume for 12 weeks
EGD
• > 15 eos/hpf ⇒ FAIL ⇒ 6 week wash out • < 15 eos/hpf ⇒ PASS ⇒ Begin next food
2nd Food • Consume for 12 weeks
EGD
• > 15 eos/hpf ⇒ FAIL ⇒ 6 week wash out • < 15 eos/hpf ⇒ PASS ⇒ Begin next food
Venter, Groetch, Meyer, Netting. A patient‐specific approach to develop an exclusion diet to manage food allergy in infants and children. January 2018,
Icahn School of Medicine 2018
Thank you
87
EAACI Isle of Wight Denver
Liam O’Mahony Task force on nutrition and immunomodulation
Hasan Arshad John Holloway Linda Mansflied Hongmei Zhang Wilfried Karmaus
David Fleischer Matt Greenhawt Dana Dabelea Deb Glueck Michaela Pulambo Brandy Ringham Kate Sauder Ivana Yang Lisa Testaverde