help! my child is allergic to peanutsand egg and milk and soy ... · step 2: allergy testing •...

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Welcome to Allied Health Telehealth

Help! My child is allergic to peanuts...and egg and milk and soy

Nutritional management of children with food allergies

Please complete evaluationhttps://www.surveymonkey.com/s/allergiesKD

Help! My child is allergic to peanuts...and egg and milk and soyNutritional management of children

with food allergies

Kate Dehlsen, Dietitian, Sydney Children’s Hospital



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Outline

1. Discuss the mechanism of a food allergies, the prevalence of food allergies in Australia and the most common food allergies in children

2. Outline the Allergy Clinic at Sydney Children’s Hospital Randwick

3. Discuss the role of the dietitian in managing children with food allergies including the features of a nutrition assessment and areas required for educations

4. Discuss hot topics in the field of food allergies in children via frequently asked questions by parents

5. Provide information on specialised food allergic disorders: FPIES, CMPI and EoE

Goal of Presentation: To improve knowledge and confidence for dietitians managing children with food allergies, therefore

optimising nutritional care for this population of children

Food Allergies 101

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ASCIA, 2013

Allergies 101

IgE mediated food allergy

• Food proteins binds to IgE antibodies bound to mast cells causing the release of large amounts of histamine and other inflammatory mediators

• Reaction is immediate (<30 minutes in children)

• Reactions involve skin, gut, airway and/or circulation

• Anaphylaxis - one or more of the following: difficulty breathing, swelling of tongue, tightness in throat, difficulty talking, wheeze, pale and floppu

• Prevalence of IgE mediated food allergy much higher in children with atopic diseases or who have an atopic family history

• 90% of food allergic reactions are caused by peanuts, tree nuts, sesame, egg, cow’s milk, fish, shellfish, wheat and soy

• Prevalence: 10% infants <1 year of age, 4-8% children 1-5 years and 2% adults

ASCIA, 2012



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Allergies 101

IgE mediated food allergy

• Can be life threatening although prevalence of severe allergic reactions are low in the paediatric population

• Higher risk on repeat exposure

• IgE antibodies can be detected on skin prick testing. This indicates a food sensitisation

• Many children are sensitised to particular foods - i.e. they have demonstrable food-specific IgE antibodies on SPT’s but a significant proportion do not go on to have a clinical food allergy

Wainstein, 2012

Allergies 101

Growing out of food allergies

• 80% of infants will outgrow a milk, wheat, soy or egg allergy by the age of 4 years

• Only 20% of children will outgrow a peanut, tree nut, sesame, fish or shellfish allergy

• Children require follow up skin prick testing and food challenges to assess whether the allergy is persisting (aim to liberalise the diet as much as possible)

ASCIA, 2012



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Allergies 101Non-IgE mediated

• Cell mediated reaction

• Delayed hypersensitivity

• Usually involves the bowel and/or skin

• Symptoms can develop hours to days after ingestion of a food

• Common symptoms: exacerbation of eczema, vomiting, diarrhea, abdominal discomfort

• Antibodies not involved so unable to be detected skin prick or antibody specific serum testing

• Diagnosis: Dietary elimination and challenges back into the diet

• Includes: FPIES, CMPI

Mixed IgE and Non-IgE mediated

• Includes EoE and eczemaASCIA, 2013

Allergies 101

Food Intolerance

• Does not involve the immune system

• Large array of symptoms including migraines, irritability of the bowel, rashes (such as hives)

• Usually caused by an inherent characteristic of the patient: e.g. sucraseinsufficiency causing a sucrose intolerance

• No reliable skin or serum test to diagnose a food intolerance

• Often require a much larger amount of food to cause clinical symptoms

• Delayed in onset and not usually life-threatening

ASCIA, 2010



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Food Allergy DiagnosisStep 1: Accurate and detailed history

• Timing of symptoms

• Reproducibility of symptoms

• Atopic history

• Previous exposure to the suspected food

• Amount of food consumed and whether ingestion did or did not occur

• Duration of symptoms before resolution

Step 2: Allergy Testing

• Skin prick testing

Step 3: Oral Food Challenge

Wainstein, 2012

Food Allergy DiagnosisSkin Prick Testing

• Detects food-specific IgE antibodies bound to mast cells

• Allergen extract drops (commercially prepared or fresh in the case of fruit abd vegetable) onto skin and then puncture wound through the drop

• Left for 15-20mins then resulting wheel measured

• Usually also has a positive (histamine) and negative (glycerosaline) control

Wainstein, 2012



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Food Allergy DiagnosisSkin Prick Testing

• Associated with false positives particularly in children with eczema

• Less frequently associated with false negatives

Negative SPT = IgE mediated allergy unlikely

Positive SPT = IgE Mediated allergy possible

In general, the larger the skin prick test wheal, the lower the probability of a false-positive

Wheal size does not necessarily indicate the severity of the reaction.

Wainstein, 2012

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Food Allergy DiagnosisRAST testing ELISA-based assay

• Measurement of food specific IgE levels in the circulation

• Historically performed using the radioallergosorbent test (RAST) but now done with an ELISA based assay

• Result given in kilo-units per litre (kU/L) of a food specific IgE, with a positive result indicated by a level of >0.35kU/L

• Also associated with high numbers of false positives

• Only test for antibodies that are suspected of causing an immune mediated reaction

• Practitioners can investigate multiple foods which can make interpretation of results difficult

Important to not make unnecessary dietary restrictions based on SPT’s or RAST testing alone. Need clinical history +/- food challenges to determine presence of a food allergy.

Food Allergy DiagnosisFood Challenges

• Gold standard for assessing presence of a food allergy

• Must be performed in a hospital with adequate resuscitation facilities and trained medical staff

• Most common indication for a food challenge:

• Positive allergy test in the absence of a clinical reaction

• Borderline allergy testing with nil prior exposure to the food

• It is suspected that the child has become tolerance to a food

Wainstein, 2012



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What happens at SCH?

Meet the SCH Allergy Clinic Team..

SCH Allergy Clinic Team

Professor John Zeigler Head of Immunology

Dr Brynn Wainstein Immunology Consultant

Dr Paul Gray Immunology Consultant

Dr Lyn Khoury and Dr Max Hopp Visiting Consultants

Dr Katie Frith Immunology Fellow

Bettina Altavilla CNC Immunology/Allergy Clinic/Food Challenge

Rebecca Saad CNS Allergy Clinic/Food Challenge

Kate Dehlsen, Penny Weigand Paediatric Dietitians

Angelica Perez-Castro, Annette Munro Secretaries

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These slides remain the property of the listed presenters. Please complete online evaluation: https://www.surveymonkey.com/s/allergiesKD 1

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SCH Allergy Clinic

• Allergy Clinic runs every Monday morning and Tuesday afternoon

• Involves the child seeing the consultant for a detailed history and determination of most appropriate allergy testing method

• Skin pick testing performed by the allergy clinic specialist nurses

• Consultant discusses results with family and decides on course of action: avoidance of allergen +/- food challenges

• Food challenge clinics run Thursday and Friday mornings

• Dietitian attends Allergy Clinic and is available for referrals made by team members

SCH Allergy Clinic• Dietitian receives appropriate handover before seeing patient including

confirmed food allergies, foods that are safe to have at home, upcoming scheduled challenges and any nutritional or growth concerns

• Dietitian will then see the patient and family to complete a nutritional assessment and education on dietary avoidance.

• Handover provided back to the team regarding any concerns, including nutritional and safety risks

• Dietitian also involved in guiding order of food challenges for multiple food allergies



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Referring to SCH Allergy Clinic• SCH Allergy Clinic only accepts paediatrician referrals

• Referrals are triaged – priority appointments for children with anaphylaxis, infants and children with multiple suspected allergies and accompanying FTT

• Varying wait time depending on triage category

• Open communication with Allergy Clinic and referring paediatrician –some cases can be managed locally

• No specific NSW areas that SCH Allergy Clinic accepts referrals from

• Dietitians can assist in identifying allergic triggers by obtaining a detailed diet history and to refer patients to a paediatrician if a food allergy is suspected but has not yet been formally diagnosed

The role of the dietitian in children with food allergies

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Dietitian Role in Managing Children with Food Allergies

• Ensuring adequate intake to support growth• Providing clear education to patient and family for ongoing self

management• Minimise the risk of future adverse food reactions• Follow up on challenges and adjust education based on these results• Ongoing liaison with medical team with clear communication on any

nutritional or safety risks for the patient• Adjusting diet as allergies resolve• Must have an excellent food knowledge on allergy specific food, recipes

and resources• Improve quality of life through education, reassurance and support

Dietetic Consult – Information Collection

1. What food is being excluded and why? What was the reaction to the food? Were reactions reproducible? Timing of ingestion of food and onset of symptoms

2. Are the restricted foods confirmed food allergies? Are there any additional food restrictions due to parental concern of cross-reactivity?

3. Previous exposure to restricted foods?

4. Assessment of results from allergy testing

5. Assess whether there has been any improvement following restriction or elimination of the suspected foods

6. If the patient’s mother following a restricted diet if she is breastfeeding?

7. Family history of atopy?

8. Does the patient have adequate medical involvement?

9. Assess current level of education on child’s allergy

10. Assess level of anxiety

11. Assess impact on child and family’s quality of life24ASCIA, 2013



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Nutrition Assessment

1. Assessment of growth

o Accurate anthropometry measurements

o Plot growth parameters on appropriate growth charts

o Children with food allergy are more susceptible to have growth faltering (Christie et al, 2002)

o Also consider a non-mediated IgE allergy for children with ongoing growth faltering not responsive to a HEHP diet and oral nutrition support

o If evidence of growth faltering, what is the patient’s ideal body weight? What are your growth goals for the patient?

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2. Reviewing biochemistry

• Consider long term (6-12 monthly) nutritional bloods if patient is on a ongoing restricted diet

• Children at risk of nutritional deficiencies: those with cow’s milk allergy and those with allergy to 2 or more foods (Somers L, 2008)

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3. Assessment of clinical status

o Child’s reaction on exposure to the allergen (anaphylaxis, hives, eczema, contact reaction, vomiting, diarrhoea)

o What medical professionals are involved? Immunologist/dermatologist/ GP/paediatrician

o Is the child still experiencing symptoms (e.g. eczema) and what is the current management plan

o Results of last SPT’s and dates of upcoming food challenges

o Any GI issues – constipation can be common for multiple food allergies

o Any food anxiety from parent or child. Focus on foods and food exclusion can increase risk of eating disorders in at risk adolescents

o Appetite, particularly for toddlers and younger children

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4. Dietary Assessment

o Younger children – useful to complete a feeding history

o Early feeding methods: breast/bottle, history of formula changes, reasons for changing formulas and whether there was a clinical improvement or not

o When were solids introduced?

o Timing of texture progression

o Mealtime behaviours

o Self-feeding skills

o Duration of mealtimes, who eats with the child, seating

o Food refusal behaviours – whole food groups or particular foods?

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Assess the child’s diet via:

o Diet History

o 24 hour Food Recall

o 3 day Food Diary

o Targeted food frequency

• Food that is offered vs food that is consumed

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• Assess for hidden sources of the allergen(s) that should be avoided in the diet

• Note if there is any unnecessary dietary exclusions

• Where does the family do their grocery shopping?

• Assess label reading skills and what measures are taken when eating out

• Are parents implementing a DIY immunotherapy approach?

• Management of food allergies at school

• Child’s involvement in identifying allergenic foods

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• Breastfeeding children:

• Frequency and duration of breastfeeds. Does mum feel a let-down?

• Maternal dietary exclusion?

• When was the allergen(s) removed from the diet?

• Clinical improvement since this time?

• Is there still small amounts of food in the diet (e.g. milk in coffee)

• Formula fed children:

• How are bottles being made up?

• How much is the child drinking vs. how much is offered?

• Frequency of bottle feeds (3rd hourly, 4th hourly etc.)

• How many bottles given per day?31

Nutrition Education – Key Components

Focus of education should be on:

• Allergen avoidance

• Identifying allergens in an ingredients list

• Education not only on foods to avoid but foods that can be eaten safely. Provide plenty of meal and snack ideas

• Ensuring nutritional adequacy

• Encouraging as much variety in diet as possible. Parents often reluctant to try new foods.

• Encouraging normal eating behaviours. May need specific education on:

• Fussy eating

• Optimising meal time environment

• Managing food refusal

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Nutrition Education – Dietary Adequacy

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ASCIA, 2013

Nutrition Education - TipsEducation needs to be given in the context of:

• Stress/anxiety

• Culturally appropriate meal and snack suggestions

• Food preparation for other siblings

• Provision of education of cooking meals and snacks – may not be able to buy a lot of commercial products

• Know allergy websites where families can buy food from

• May need to ring around some shops in the child’s area to identify places that can provide appropriate foods

• New phone and tablet apps to assist in label reading and eating out

• Ensuring normalcy in the child’s diet as much as possible

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Dietetic Follow-up• Regular reviews recommended, particularly for children with multiple food allergies

and/or history of growth faltering

• Review growth trends and nutritional intake

• Reviewing parental confidence in allergen exclusion, including competency in reading food labels

• Review implementation of previous dietetic recommendations

• Adjust dietary recommendations based on food challenge and/or repeat SPT results

• Report any concerns to medical team for further advice

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Frequently Asked Questions (FAQ’s)

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How do I reduce the risk of my child developing a food allergy?

• Consideration may be needed for high-risk children (strong family history of atopy, usually >2 immediate family members with atopy) (Wainstein, 2012)

• Not the dietitian’s role to make this decision

• Consideration may be needed for high-risk children (strong family history of atopy, usually >2 immediate family members with atopy)

• For breastfeeding children with allergic disease, maternal exclusion may be advised if:

• Frequent and severe vomiting

• Severe and unresponsive eczema

• Generalised cutaneous symptoms

• Ongoing diarrhoea (with or without blood and/or mucous present)

• FTT

• Extreme irritability and feeding difficulties37

• Over-arching data concludes there is no benefit for maternal dietary restriction in pregnancy and lactation to assist with preventing food allergies in the general

population (Osborn & Sinn, 2006)


Infant feeding and introduction to solids

• ASCIA recommends breastfeeding for at least 6 months and can continue beyond 12 months, or for as long as mother and infant wish to continue

• Introduction of solids from 4-6 months, when the infant is developmentally ready

• Aim to continue breastfeeding whilst introducing complementary foods

• There is little evidence that delaying the introduction of complementary solid foods beyond 6 months reduces the risk of allergy

• There is no particular order for introducing complementary foods and one new food can be introduced every 2-3 days to allow for observation for possible adverse reactions

• There is insufficient evidence to delay the introduction of potentially allergenic foods to prevent food allergies or eczema. This also applies to infants with siblings who already have allergies to these foods.

38ASCIA, 2010



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Infant feeding and introduction to solids

• Increased food diversity in the first year of life is inversely associated with allergic diseases, particularly asthma and food allergy

• Children with low food diversity in the first 12 months of life have antibody markers placing them at greater risk for allergic diseases

• Between the age of 6 to 12 months is best window for expanding diet variety of protection of food allergies

• Delayed introduction (after 12 months) of potentially allergenic foods (e.g. egg) is associated with higher risk of developing a food allergy to that food

• At age 4 to 6 months, first exposure as cooked egg reduced the risk of egg allergy compared with first exposure as egg in baked goods

39Roduit et al, 2014; Koplin et al, 2010

What formula should I give my child?

40Kemp A et al, 2008



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Suitable milk drinks < 12 months

41ASCIA, 2013

Infants with a history of allergic disease in the infant’s parents or siblings may be placed on a partially hydrolysed formula (usually labelled “HA” or hypo-allergenic). These formulas are not suitable for children who have already developed cow’s milk allergy.


Suitable milk drinks > 12 months of age

42ASCIA, 2013



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Should I buy those biscuits that may contain traces of milk?

• Precautionary food labelling: “may contain traces of”, “made in the same factory”

• Present on >50% of packaged food items

• 78-84% parents with children with a history of anaphylaxis were confused by these statements and did not know whether the food was safe to eat irrespective of the wording of the labels

• Wording affected consumer behaviour: 65% parents ignored the statement “made in the same factory” compared while 22% ignored “may be present”

• Currently, reference doses are being established for 11 commonly allergenic foods to guide a rational approach for manufacturers in providing credible and uniform precautionary labelling across industries and products

• Reference doses will guide the Voluntary Incidental Trace Allergen Labeling (VITAL) 2.0 thresholds now recommended in Australia

43Murdoch Children’s Research Institute, 2013, Zurzolo et al, 2013

My son is allergic to nuts, milk, egg, wheat and fish. What can he eat?

• Multiple food allergies can impact growth, nutritional adequacy, quality of life

• Evidence shows that children with 2 or more food allergies were shorter than those with 1 food allergy

• Multiple food allergies is associated with children meeting less than 70% RDI for calcium, vitamin D and vitamin E

• Feeding difficulties is also evident in children who have had negative experiences with food exposure. Food aversion, refusal, gagging and anxiety often present in this population. Oromotor development can be impacted if food allergies and therefore exclusions are diagnosed at a young age

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Wang J, 2010Christie L et al, 2002Haas A & Muane N, 2009



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My son is allergic to nuts, milk, egg, wheat and fish. What can he eat?

• Important to know FSANZ Food Standards Code 1.2.3 to guide education on identifying potentially allergenic foods

• Focus education on label reading using practical examples, socialisation situations and provide this for that meal and snack ideas

• It is VERY important that the child is linked in with a tertiary allergy clinic to food challenges can be done as soon as safely possible

• Also important for a paediatric immunologist to complete a detailed history and ONLY test for the foods that the child seems to be sensitised to on history. Foods that are currently in the child’s diet and tolerated, should NOT be tested

• Food diaries also important to review micronutrient adequacy – important to know common vitamin and mineral supplements that may need to ensure RDI’s are met

• Children with multiple food allergies may also benefit from formula supplementation

• Growth needs to be carefully monitored and any concerns fed back to paediatrician and allergy clinic team

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A Crash Course in Specific Allergic Disorders

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Food Protein Induced Enterocolitis: FPIES

• Non IgE delayed immunological reaction to specific food proteins

• Reactions only involve the gastrointestinal system

• Symptoms of profuse vomiting (and sometimes diarrhoea) most commonly occur 2-4 hours after eating a food which has been recently introduced into the diet

• 50% of children react on first exposure

• Other symptoms can include FTT and in rare cases hypovolaemic collapse

• Most children react to 1-2 foods (cross reactions). These include:

• Cow’s milk and soy

• Rice and oats

• Chicken and turkey

• First line of formula if required: Extensively hydrolysed formula (Pepti Junior Gold, Alfare, AllerPro)

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Food Protein Induced Enterocolitis: FPIES

• Children require strict avoidance of protein and cross-reacting protein

• Most children outgrow FPIES by 5 years of age

• Challenges require hospital admission with cannulation and access to IV fluids if required

• Dietitian not usually involved in this challenge process until after a food have been ruled out or continues to require restriction – further parental education may be required at this point

• SCH typically admits children for a challenge 12 months after first reaction

• Feeding difficulties are common in children with FPIES, particularly with delayed diagnosis

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ASCIA, 2014Nowak-Wegrzyn A & Muraro A, 2009



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Protein-Induced Enteropathy

• Most common cow’s milk protein intolerance (CMPI)

• Non IgE mediated reaction of the gastrointestinal tract specifically related to inflammation and/or dysmotility

• Symptoms of CMPI are variable and include oral and perioral swelling, dysphagia and food impaction, vomiting, regurgitation, dyspepsia, early satiety, anorexia and food refusal (delayed gastric emptying), diarrhoea (with or without malabsorption or protein loss due to enteropathy), rectal bleeding and failure to thrive

• Diagnosed by a paediatric gastroenterologist

• Consider SPT’s and endoscopies (upper or lower) to rule out other disease manifestations. Scool microscopies will indicate presence of white or red blood cells suggestive of enteropathy

• If symptoms are consistent with CMPI, a diagnostic challenge of cow’s milk protein exclusion should be initiated for a set amount of time (up to 4 weeks). If no improvement, consider also excluding soy and commencement of an extensively hydrolysed formula if the child is not breastfeeding

49Koletzko S, et al, 2013


• Most common cow’s milk protein intolerance (CMPI)

• Non IgE mediated reaction of the gastrointestinal tract specifically related to inflammation and/or dysmotility

• Symptoms of CMPI are variable and include oral and perioral swelling, dysphagia and food impaction, vomiting, regurgitation, dyspepsia, early satiety, anorexia and food refusal (delayed gastric emptying), diarrhoea (with or without malabsorption or protein loss due to enteropathy), rectal bleeding and failure to thrive

• Diagnosed by a paediatric gastroenterologist

• Consider SPT’s and endoscopies (upper or lower) to rule out other disease manifestations

50Koletzko S, et al, 2013



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• Breastfeeding mothers require exclusion of cow’s milk +/- soy

• Need to ensure nutritional adequacy of mother’s diet (calcium requirements higher in lactation)

• In non-breastfeeding infants, exclusion of all cow’s milk products and any other mammalian milks (goat’s, sheep) is required

• An extensively hydrolysed formula should be started if no improvement with soy formula

• Education required on a cow’s milk +/- soy free diet for introduction to solids as well as providing information on label reading

• Most children outgrow a CMPI by the age of 3 years

• Gastroenterologists will usually guide when cow’s milk and soy can be re-challenged back into the diet

• Soy usually challenged first, challenge first in mother’s diet then the child’s. If tolerated, proceed to cow’s milk

• ESPGHAN has guidelines on suggested challenge protocols (Koletzko S, et al, 2013)

• Some cases, egg is also excluded

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Eosinophilic Esophagitis (EoE)

Chronic, mixed IgE and non-IgE immune mediated inflammatory disease, characterised clinically by symptoms of oesophageal dysfunction and histologically by eosinophil predominant inflammation(>15 eosinophils per HPF)

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• Esophageal rings• Thickened pale

mucosa• Furrows and

exudates



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Eosinophilic Esophagitis

53Papadopoulou, Koletzko et al, 2014

Dietary Management of EoE

ESPGHAN Guidelines 2014:

• Elimination Diets

• Elemental Diet: Amino Acid Formula

• Empirical Elimination Diet

• Targeted Elimination Diet

Dietary treatment for 4 to 12 weeks is a therapeutic option in all children with a confirmed diagnosis of EoE. The decision as to which

of the specific dietary approaches to use should be individualised according to the child’s specific needs and family circumstances.

54Papadopoulou, Koletzko et al, 2014



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Summary

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Summary

• Food allergies are increasing in prevalence in Australian children

• Can require complex management particularly for children with multiple food allergies, CMPI, FPIES and EoE

• Dietitian plays an important role in optimising growth and ensuring nutritional adequacy

• Children with food allergies require a multidisciplinary team approach. They should not be managed in isolation

• Important to diagnose food allergies correctly and prevent misdiagnoses

• Dietitians should be comfortable in managing children with food allergies and seek assistance when unsure

• Important for dietitians to recognise what their role is and is not and know their limitations

• Communication amongst a team is essential

• Children with food allergies require regular review, not only with the dietitian but with the allergy team to monitor food sensitivities

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Questions?

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References

• ASCIA, 2010, Infant Feeding Advice, Available at allergy.org.au

• ASCIA, 2010, Food Allergy: Patient Information Resource, Australasian Society of Clinical Immunology and Allergy, Available at http://www.allergy.org.au/images/stories/aer/infobulletins/2010pdf/AER_Food_Allergy.pdf

• ASCIA, 2012, ASCIA Food Allergy E-Training, Australasian Society of Clinical Immunology and Allergy, Available at http://etrainingdiet.ascia.org.au/

• ASCIA, 2013, Health Professional Information Paper: Nutritional Management of Food Allergy, Australasian Society of Clinical Immunology and Allergy

• ASCIA, 2014, Food Protein-Induced Enterocolitis Syndrome (FPIES), Available at http://www.allergy.org.au/images/stories/aer/infobulletins/2014/AER_FPIES_2014.pdf

• Christie L, Hine R, Parker J & Burks W, 2002, Food allergies in children affect nutrient intake and growth, Journal of the American Dietetic Association, 102(11):1648-1651

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References

• Haas A & Huane N, 2009, Clinical presentation of feeding dysfunction in children with eosinophilic gastrointestinal disease, Immunology, Allergy Clinical North America, 29:65-75

• Kemp A et al, 2008, Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Medical Journal of Australia.188:2

• Koletzko S et al, 2012, Diagnostic approach and management of cow’s milk protein allergy in infants and children: ESPGHAN GI Committee Practical Guidelines, Journal of Paediatric Gastroenterology and Nutrition, 55(2): 221-229

• Koplin J et al, 2010, Can early introduction of egg prevent egg allergy in infants? A population-based study, Journal of Allergy and Clinical Immunology, 126(4):807-813

• Murdoch Children’s Research Institute, 2013, Allergen reference doses for precautionary labelling, available at http://www.mcri.edu.au/news/2013/september/precautionary-labelling/

• Nowak-Wegrzyn A & Muraro A, 2009, Food protein-induced enterocolitis syndrome, Current Opinions in Allergy and Clinical Immunology, 9(4):371-377

• Osborn D & Sinn J, 2006, Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants, Cochrane Database of Systematic Reviews, CDC003664

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References

• Papadopoulou A, Koletzko S et al, 2014, Management guidelines of eosinophilic esophagitis in childhood, Journal of Paediatric Gastroenterology and Nutrition, 58:107-118

• Roduit C et al, 2014, Increased food diversity in the first year of life is onversely associated with allergic diseases, Journal of Allergy and Clinical Immunology, 133:1056-1064

• Somers L, 2008, Food allergy: Nutritional considerations for primary care providers, Paediatric Annals, 37(8):559-568

• Wainstein B, 2012, Food Allergy in Children, How to Treat, Available at www.australiandoctor.com.au

• Wang J, 2010, Management of the patient with multiple food allergies, Current Allergy and Asthma Report, 10(4): 271-277

• Zurzolo G, et al, 2013, Perceptions of precautionary labelling among parents of children with food allergy and anaphylaxis, Medical Journal of Australia, 198(11): 621-623

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help! my child is allergic to peanutsand egg and milk and soy ... · step 2: allergy testing •...

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