food allergy in infancy and beyond
DESCRIPTION
Presented at the first meeting of ISPEN in DublinTRANSCRIPT
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
2011
Irish Food Allergy Network (IFAN) care pathways for milk, egg, nut & others.In development 2011/2012
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Patient Z: first contact
• Summer time• 4 year old girl, only child• Single mum, smoker• Living in caravan in granny’s garden
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Growth
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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.
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
What do you do?
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
“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”.
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Energy requirements
Approx 300kcal energy deficit for normal growth requirements
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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 ?
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Anorexia
• Find & treat cause if possible– Infection– Stress
• Consider GI co-morbidities
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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.
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
Bone health
• Supplement until milk tolerance is established• Consider divided dose of calcium• RDA for age
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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.
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
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.
Ruth Charles, Paediatric Dietitian. www.nutrikids.ie
? 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.