accommodating and educating students with food allergy
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Accommodating and Educating Students with Food Allergy. Marion Groetch, MS, RD Director, N utrition Services [email protected] Jaffe Food Allergy Institute Mount Sinai School of Medicine New York, New York. Learning Objectives. - PowerPoint PPT PresentationTRANSCRIPT
Accommodating and Educating Students with Food Allergy
Marion Groetch, MS, RDDirector, Nutrition [email protected] Jaffe Food Allergy Institute
Mount Sinai School of MedicineNew York, New York
Learning Objectives
Define the difference between food allergy and food intolerance.
Describe the steps involved in the allergy evaluation. Acquire the skills and identify resources to provide
comprehensive education for allergen elimination diets. Understand the nutritional risks of allergen elimination
diets. Identify resources for Job Corps food service staff,
nurses and center personnel.
Groetch 2011
Guidelines for the Diagnosis and Management of FA in the US:
NIAID-Sponsored Expert Panel Report
Based on comprehensive review and objective evaluation of the recent scientific and clinical literature on FA.
Working with more than 30 professional organizations, federal agencies and patient advocacy groups led the development of “best practice” clinical guidelines.
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 of Food Allergy (FA)
Food allergy An adverse health effect arising from a specific
immune response that occurs reproducibly on exposure to a given food
Food intolerance An untoward response to food substance that is not
immunologically mediated
Food Allergies Can Be Life-Threatening
More people die each year from food allergy-induced reactions than to reactions to insect stings.
Food allergy is believed to cause an estimated 30,000 emergency department visits each year in the US.
The potential severity of a food allergic reaction cannot be predicted. Once a reaction begins, there is no way of predicting how severe it may become.
Anaphylaxis
Allergic reaction that occurs most commonly within minutes (but can be up to several hours) after contact with an allergy causing substance.
A serious allergic reaction that is rapid in onset and may cause death.
Epinephrine is the first line treatment in all cases of anaphylaxis.
Eosinophilic esophagitis
Eosinophilic gastritis
Eosinophilic gastroenteritis
Atopic dermatitis
Food Allergy
Immunoglobulin E (IgE)-Mediated
(most common)
Non-Immunoglobulin E Mediated
Cell-Mediated
Immunologic
Anaphylaxis Oral Allergy
Syndrome Immediate
gastrointestinal allergy
Asthma/rhinitis Urticaria Morbilliform
rashes and flushing
Contact urticaria
Protein-Induced Enterocolitis
Protein-Induced Enteropathy
Allergic proctitis
Dermatitis herpetiformis
Contact dermatitisSampson H. J Allergy Clin Immunol 2004;113:805-9, Chapman J et al. Ann
Allergy Asthma & Immunol 2006;96:S51-68.
Diagnosis of IgE-Mediated Food Allergy
Role of the primary care physician or Board Certified Allergist
Detailed medical and dietary history with a focus on symptoms
Identify general approach Allergy vs. intolerance IgE vs. non-IgE
Thorough physical exam Diagnostic tests to rule out other medical conditions
not related to food allergy
Food Allergy Testing—IgE
Prick Skin Test (PST)—IgE Serum IgE–(CAP–System FEIA) Quantitative
measurement of food specific IgE Double Blind Placebo Controlled Food Challenge-
Considered “Gold Standard” for FA diagnosis
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
Food Allergy Guidelines
Serum IgE or PST may be used to identify foods that potentially provoke IgE-mediated food induced allergic reactions, but alone, these tests are not diagnostic.
The expert panel does not recommend routine screening for food allergy.
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
Severity of Food Allergy
The severity of a potential allergic reaction can not be predicted by IgE level or by size of a PST.
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
Dietary Manipulation as a Diagnostic Tool
The food allergy guidelines suggests elimination of one or few specific foods to make the diagnosis of FA, especially in non-IgE medicated food allergic disorders.
Useful when chronic symptoms or delayed symptoms make determining the cause difficult.
Removal of the suspected allergen with anticipated significant improvement or remission of symptoms.
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
Disorders Not Proven to be Related to Food Allergy
Migraines Behavioral / Developmental disorders Arthritis Seizures Inflammatory bowel disease
Unproven Diagnostic Tests
Basophil histamine release/activation
Lymphocyte stimulation Facial thermography Gastric juice analysis Endoscopic allergen
provocation Hair analysis
Applied kinesiology Provocation neutralization Allergen-specific IgG4 Cytotoxicity assays Electrodermal test (Vega) Mediator Release assay
(LEAP)
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
Education and Training: Avoidance
The food allergy guidelines suggest providing education and training to all individuals with documented food allergy on how to recognize labeling of food allergens on food labels.
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
Avoidance
Avoidance sheets Reading food labels Understanding cross contact in manufacturing Understanding cross contact in restaurant,
food service or home kitchen Minor ingredients
www.cofargroup.org and www.foodallergy.org
Label Reading
Read the entire product label each and every time an item is purchased.
Label ReadingFood Allergen Labeling Consumer
Protection Act (FALCPA) Milk Egg Wheat Soy Peanut Tree nut* Fish* Crustacean shellfish* *Specific species must be listed
"Food allergen labeling consumer protection act” www.cfsan.fda.gov
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
The Amount of Allergen in Products Assessed
Hefle et al JACI 2007
0 2 4 6 8 10 12
May contain
Sharedequipment
Shared facility 7/68
3/57
2/51
Overall 7% of all products (n=179) with advisory statements tested contained detectable allergen residue.
% of products with detectable allergen
With permission, Scott Sicherer, MD
Risk Associated with Milk Advisory Statements
Overall milk was detected in 36% of products (n=147) with milk advisory statements
Dark chocolate had the highest % with detectable milk in 82% of samples with milk advisory statements.
Crotty JACI 2010
Food Allergy Guidelines
NIAID guidelines suggest avoiding any product that has any advisory statement for your allergen.
Boyce JA, Assa'ad A, Burks AW, et al. JACI 2010.
Label Reading Summary
Read product labels each and every time an item is purchased.
Look at the ingredient list and precautionary labels. Avoid products that have a precautionary statement
for your allergens. May need to call manufacturers for additional product
information.
Food Service
Managers should conduct food allergy training and review of the food allergy management plan periodically to be sure that both new hires and existing employees are properly trained.
Employees should understand how cross-contact can occur.
The food service establishment should have at least one person on duty, ideally the manager, who can handle questions and special requests from students with food allergies.
Groetch 2011
Food Service
Other staff members should know who the food allergy manager is and should always direct questions about food allergies to that person.
A cafeteria should be able to supply, upon request, a list of ingredients for a menu item.
If a mistake occurs with an item prepared for a student with a food allergy, the only acceptable way to correct the situation is to have the kitchen staff discard the incorrect item and remake it.
If a student is having an allergic reaction, call 911 and get medical help immediately!
Groetch 2011
Cross-Contact in the Cafeteria
Utensils, dishes Cutting boards Grinders, blenders Hands Gloves (no latex) Processors
Salad bars Pots, pans Fryers Grills etc., etc...
Consider anything used for more than one food and not
cleaned completely!
Cross Contact
Problem Allergen-free foods may come in contact with an
allergen in storage, in the refrigerator or the cupboard.
Solution Designate a separate shelf in the refrigerator and
cupboard for allergen-free foods. This shelf should be above the shelf that may store foods with potential allergens. Consider using stickers to identify “safe” foods.
Groetch 2011
Cross Contact Problem
A knife used to spread peanut butter may also be dipped in the jelly jar, tainting the jelly with peanut protein.
Solution Keep a separate jelly jar for the students with allergies. Use clean
knives in jelly first. Problem
Preparing an allergen (chopping walnuts on a counter surface) and then a safe food (slicing tomatoes) without properly cleaning.
Solution Prepare the allergen safe food first. Clean cooking equipment
including the cooking area with hot soapy water.
Cross Contact
Problem Plain French fries are fried in a deep fat fryer that
was used to fry onion rings (containing milk, egg, and wheat).
Solution Fry allergen-free foods separately in clean oil or in
a dedicated fryer.
Cross Contact
Problem Cafeteria lines and buffets may have greater risk of
cross contact due to shared utensils and spills. Solution
Keep the allergen-safe food completely separate to prevent cross contact.
Groetch 2011
To Avoid or Not to AvoidMinor ingredients and cross reactive proteins
To Avoid or Not to Avoid
A patient with corn allergy? Corn oil or corn syrup?
A patient with soy allergy? Soy oil or soy lecithin?
A patient with peanut allergy? Peanut oil?
Crevel, Kerkhoff, Konig. Allergenicity of refined vegetable oils. Food and Chemical
Toxicology. 2000;38:385-393.
To Avoid or Not to Avoid
A patient with sesame allergy? Sesame oil?
A patient with egg allergy? Egg white or egg yolk?
A patient with peanut allergy? Tree nuts or other Legumes?
Sicherer SH. Clinical implications of cross-reactive food allergens. JACI 2001;108:881-890
www.foodallergy.org
Every student with a food allergy should have an Emergency Treatment plan signedby their MD.
It Takes a Team Student/ Health and Wellness Center /Cafeteria/ Center personnel Student informs Health and Wellness Center and the Cafeteria of the food
allergy Health and Wellness Center ensures the student has an Emergency
Treatment plan signed by MD Health and Wellness Center and Cafeteria communicate information about
student’s allergy
It Takes a Team: Cafeteria Strict Avoidance – one bite can hurt Know ingredients/Know the student with allergies Read all labels – contact manufacturers Store ingredients to prevent cross contact Use clean utensils, cooking areas and cooking equipment May consider a designated area
for prep of allergen-free foods. Prepare allergen free foods first,
cover and remove from cooking area
Serve separately – not from cafeteria line
It Takes a Team
Assure correct personnel are identified Identify those trained in food prep for the students with
allergies Identify those trained to answer questions about ingredients
and food prep methods Identify those who will enact emergency action in the event
of a reaction Identify JC center environments that might pose a risk and
create procedures to reduce risk If a reaction occurs, activate emergency action
promptly
3 R’s of an Anaphylaxis Plan
Recognize the symptoms early React quickly-provide appropriate medication,
call 911 Review what caused the reaction
***Every center should have a plan for managing food allergies
Intramuscular epinephrine—EpiPen or Twinject
Prompt administration is key to surviving anaphylaxis. Fatalities have resulted from a delay/failure to give epinephrine.
Follow up in the ED or call 911 4-hour observation period
Treatment of Food Anaphylaxis
Nutrition Counseling
Food Allergy Guidelines recommends all children with food allergy receive nutrition counseling and close growth monitoring.
Boyce et al. Guidelines for the diagnosis and management of foods allergy in the US. JACI 2010
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/kwashiorkor/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.
Flammarion et al. Pediatr Allergy Immunol. 2011; 22: 161-165.
Cow’s Milk Allergy
Foods to avoid: milk, butter, cheese, yogurt, custard, ice cream, puddings…as well as numerous manufactured products such as many margarines, breads, cookies, cakes, chewing gum, cold cuts, crackers, cereals, non-dairy products, processed and canned meats and many frozen and refrigerated soy products
Nutritional Contribution of CM
Calcium Vitamin D Vitamin A Vitamin B12 Riboflavin Pantothenic acid Phosphorous Protein and fat
Comparison of CM SubstitutesCM orCM 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
Almondenriched
50 1 2.5 300 / 100
Wheat Avoidance
Bread, cereal, pasta, crackers, cookies, cakes, condiments, marinades, cold cuts, soups, low-fat or non-fat products
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.
Alternative Grains
Rice Corn Oat Rye Barley Buckwheat Amaranth Quinoa Millet
Cross-Reactive Grains
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 patient history or by the allergist.
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 other dietary patterns (vegetarian)
Future Directions
Oral Immunotherapy Sublingual Immunotherapy Food Allergy Herbal Formula (Chinese herbal) Cooked milk and cooked egg
Food Allergy Management
There is no cure—avoidance is the only way to prevent food allergic reactions
Avoidance issues have many nuances and extensive education is required to prevent accidental ingestions
Create policy’s and provide training in your food service establishments
Avoidance diets are not without nutritional risk
Groetch 2011
Resources for Food Service, Nurses and Educators
Welcoming Guests with Food Allergy Food Allergy Training Guide for College Food
Service How to Care for Students with Food Allergies: What
Educators Should Know Online Food Allergy Toolkit for School Nurses
www.foodallergy.org
Groetch 2011
Resources The Food Allergy and Anaphylaxis Networkwww.foodallergy.org Food Allergy Initiativewww.faiusa.org American Academy of Allergy, Asthma and Immunologywww.aaaai.org The Jaffe Food Allergy Institute212-241-5548 CoFAR www.cofargroup.org
Resources
Understanding and Managing your Child’s Food Allergies by Scott H. Sicherer
Food Allergies for Dummies by Robert Wood Pediatric Nutrition Care Manual - online UpToDate has extensive FA information topics CoFAR Food Allergy Education Program
www.cofargroup.org
References
Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J Am Diet Assoc. 2002;102:1648-1651.
Isolauri E, Sutas Y, Salo MK, Isosomppi R, Kaila M. Elimination diet in cow's milk allergy: Risk for impaired growth in young children. J Pediatr. 1998;132:1004-1009.
Henriksen C, Eggesbo M, Halvorsen R, Botten G. Nutrient intake among two-year-old children on cows' milk-restricted diets. Acta Paediatr. 2000;89:272-278.
Fortunato JE, Scheimann AO. Protein-energy malnutrition and feeding refusal secondary to food allergies. Clin Pediatr (Phila). 2008;47:496-499.
Liu T, Howard RM, Mancini AJ, et al. Kwashiorkor in the united states: Fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol. 2001;137:630-636.
Fox AT, Du Toit G, Lang A, Lack G. Food allergy as a risk factor for nutritional rickets. Pediatr Allergy Immunol. 2004;15:566-569.
American academy of pediatrics. Committee on Nutrition. Hypoallergenic Infant Formulas. Pediatrics. 2000;106:346-349.
References (continued)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.
"Food allergen labeling consumer protection act of 2004" www.cfsan.fda.gov
Sheth SS, Waserman S, Kagan R, Alizadehfar R, Primeau MN, Elliot S et al. Role of food labels in accidental exposures in food-allergic individuals in Canada. Ann Allergy Asthma Immunol 2010; 104(1):60-5.