1. Sharlene Coombs, RD, CD, CSP, CNSD
Primary Children’s Medical Center
Sharlene.coombs@imail.org
6-25-2011

2. Foods, liquids, supplements and
medications are taken by mouth
(or by tube).
Digestion and absorption
occur in the
gastrointestinal tract.

3. Immune system responds as
“foreign but safe”.
Food components are taken to
body sites via blood for cell
renewal and energy.
OR
Immune system responds as
“foreign and a threat!”
Immune system defends the
body. Inflammatory mediators
are released into local tissues
and transported to distant
sites in the body via blood.

4. Inflammatory mediators are released
and transported to distant sites
in the body via blood.
Allergy symptoms develop in body
Respiratory: congestion, runny nose,
asthma
Gastrointestinal: pain, upset stomach,
diarrhea, nausea, vomiting
Skin and mucous membranes: hives,
itching, swelling, rashes
Cardiovascular: low blood pressure, rapid
and /or weak pulse
Systemic: Anaphylaxis

5. — Restriction of offending food(s)
— Adequate calories and protein
— Adequate vitamins and minerals
— Establish and maintain good health

6. “Life with food allergies remain difficult, with the
only reliable therapy being complete restriction or
elimination of the responsible food(s) allergen and
emergency management of reactions when
allergens are accidentally ingested…
…Ultimately, the balance must be found between
efforts to mitigate the disease and to
sustain the overall quality of life.”
www.allergyadvisor.com

7. — Seek appropriate medical help
— Follow recommendations- get in writing
— Follow thru on appts and/or call if problems continue
— It does help to have food log or record of problems
— Learn all you can about the foods to avoid
— Learn to cook from “scratch”- back to basics though not
easier than eating out or processed foods.

8. — Caregivers need to support one another
— Caregivers need to have eating plans
— All caregivers need to understand emergency plan
— Infants and children with allergies may need more
frequent weight and height evaluations
— Provide the “best” nutrition you can- this may
include high calorie foods- not just fruits and veg.

9. — Buy & prepare appropriate/safe foods
— Offer meals and snacks every 3-4 hours apart,
for 5-6 opportunities to eat and drink each day
— Do not allow sipping and grazing all day
— At each meal and snack, offer protein, starch, fruit
or vegetable and 4-6 oz milk or milk substitute
— 1 Tbsp of each food group per year of age of the child

10. To eat
or not to eat
It is ok for them to feel hunger-
a natural driving force to eat and drink

11. Do Don’t
— Offer reasonable — Force, punish or
choices, ie white or demand the child eat/
chocolate milk, not drink
water instead — Give in to child’s
— It helps to be a good demands- even if
role model underweight
— Meal times should be
pleasant, not centered
on what the child is or
is not eating

12. Calories
Protein
Vitamins
Minerals
Fluids

13. — Carbohydrates
— Protein
— Fat

14. — Sugars, starches, fibers
— Glucose is preferred source of energy
— Many vitamins and minerals in CHO foods
— Excess intake is stored in liver and converted to fat
— Foods: Sugars, starches, grains, fruits, vegs & dairy

15. — Essential and non-essential amino acids
— Amino acids build, repair and maintain body cells
— Provide energy when CHO and fat are missing
— Participate in chemical reactions in the body
— Foods: Eggs, meats, fish, poultry, dairy,
— nuts, beans, grains

16. — Essential and non-essential fatty acids
— Integral to the nervous system; insulation
— More calorie dense than CHO or protein
— Foods: Dairy, butter, nuts, seeds, animal fat,
coconut milk/oil, vegetable oils

17. — Vitamins
— 13 chemicals; various functions
— Fat and water soluble
— Essential for health
— Minerals
— 15 elements: various functions and structure
— Major and trace elements
— Essential for health
— Water
— Provided from food and fluids
— Essential for health

18. — Vitamin A
— Function: Vision, skin, membranes
— Food sources: liver, fish oil, dairy products
— Vitamin E
— Function: Antioxidant, improves immune system
— Food Sources: nuts, seeds, oils, wheat germ
— Vitamin K
— Function: blood clotting
— Food sources: Dark green veggies, liver, wheat bran

19. — Vitamin D
— Function: Bone health, immunity, reproduction,
insulin secretion. Maybe prevents certain cancers.
Children with low levels have higher incidence of food
allergies.
— Dietary Reference Intake: increased to 400-1300 IU
— Food sources: egg yolk, liver, fish oil, fortified milk
and milk substitutes. Also the “Sun”.
— Supplements: Liquid- “Wellesse” 2 tsps = 1000 IU.
Tablets: 500-50,000 IU.

20. — Thiamin, B1
— Riboflavin, B2
— Niacin, B3
— Pyridoxine, B6
— Biotin (found in eggs, leafy greens)
— Pantothenic Acid
— All function as coenzymes in metabolism
— Destroyed with overcooking, light and heat
— Foods: dairy, meats, legumes, whole grains, nuts

21. — Vitamin C
— Function: Antioxidant, healthy bones, gums, teeth,
blood vessels, brain function, iron absorption
— Foods: Citrus fruits, bell peppers, tomato, kiwi,
red berries
— Folate, folic acid, B9
— Function: Synthesis for DNA, gene expression &
regulation. Critical 21-27 days after conception.
— Foods: Orange juice, leafy greens, yeast, liver, soy,
fortified grains, broccoli, eggs

22. — Calcium
— Function: Bones, muscle contraction, blood clotting
— Vitamin D helps absorption. Excess protein, salt,
caffeine and alcohol decrease absorption.
— Foods: Dairy, fortified foods and drinks, nuts,
legumes, dark greens ( limited absorption)
— Dietary Reference Intake: (recommended intake)
Age Calcium, mg/day
1-3 years 700
4-8 years 1000
9-18 years 1300
19-50 years 1000
51 + years 1200

23. — Phosphorous
— Function: Bones, teeth, cell membranes, enzymes
— Balance of calcium and Vitamin D needed
— Diet often restricted in kidney failure
— Foods: Dairy, meats, poultry, fish, eggs, soda pop
— Not usually supplemented

24. — Iron
— Function: transports oxygen, picks up CO2, healthy
immune system, growth, cognition, DNA synthesis
— Foods: meat, fish, poultry, dark green leafy veg.
— Vit. C increases absorption. Calcium prevents.
— Zinc
— Function: DNA/RNA, cell division, wound healing,
part of enzymes, needed for bone growth.
— Foods: meats, wheat germ, shellfish, liver, cheese,
eggs, whole grains, nuts/seeds, legumes

25. — Magnesium
— Function: enzyme systems, glucose metabolism,
bone health, prevent dental caries, muscle function
— Foods: Beans, whole grains, seafood, leafy greens
— Iodine
— Function: Essential for thyroid hormones, regulate
body temp., metabolic rate, growth, reproduction
— Foods: iodized salt, saltwater fish/seafood
— Iodized salt is not used in processed foods.

26. — Fluoride
— Function: Interferes with plaque formation
— Foods: Fortified drinking water, small amounts in
fruits & veg.
— Sodium
— Function: acid-base balance, fluid balance, muscle/
nerve activation- small amount, but essential.
— Foods: table salt, cheese, dairy, processed foods
— Potassium
— Function: similar to sodium
— Foods: vegetables, fruits, dairy, meats, grains

27. — Chromium
— Whole grains, wheat germ ,liver, meat
— Copper
— Bread, potatoes, grains, dried beans, nuts, seeds
— Chloride
— Table salt
— Manganese
— Whole grains, coffee, tea, dried beans, nuts
— Molybdenum
— Whole grains, wheat germ, liver, meat

29. Vitamin
Food A D E C B1 B2 B3 B6 B12 B9
Milk + + + + + +
Soy + + + + + +
Egg + + + + + + + +
Wheat + + + +
Peanut + + + +
Tree nut + + +
Fish/shellfish + + + + + +
Includes fortified/enriched cereals and flours.
Fortified/enriched soy milks.
Cheeses, yogurt, ice cream not usually fortified with Vit D

30. Mineral
Food Calcium Iron Zinc Mag. Sodium Potassium
Milk + + + + +
Soy + + + +
Egg + +
Wheat + + + + +
Peanut + + + +
Tree nut + + + +
Fish/shellfish + + + + + +
Includes fortified wheat cereals and flours. Fortified soy milks.
Salted nuts and saltwater seafood

31. — Optimal amount based on weight (textbook)
— 0-10 kg= 100 ml/kg
— 10-20 kg= 1000 ml + 50 ml for every kg >10 kg
— 20+ kg= 1000 ml + 20 ml for every kg >20 kg
— Weight in lbs divided by 2.2 = kg
— Divide total ml’s by 30 ml/oz = ounces

32. — Fiber
— Prebiotics and Probiotics
— Omega 3 fatty acids

33. — Replace with comparable foods or drinks
— Look for fortified products
— Take vitamin/mineral supplements
— Monitor weight/growth
— Consider monitoring blood work for key nutrients
— Vit D, iron, zinc

34. Comparison of Cow Milk Alternatives (8 oz)
Drink Calories Protein, grams Calcium, mg
Cow’s milk, whole 150 8 276
Soy milk* 100-130 6 300-350
Rice milk* 120-130 1 300
Coconut milk* 80-550 1-5 100-450
Hemp milk* 100 4 300
Oat milk* 130 4 100
Potato milk* 70-110 0 300
Almond milk 40-90 1 200-450
Orange juice* (some) 110 2 350
Elecare, 30 kcal/oz 240 7.4 278
Neocate Jr 240 7.9 271
Splash 237 5.9 147
*Calcium is not naturally occurring- fortified

35. — http://www.nal.usda.gov/fnic/foodcomp/search/

36. Non-Wheat Grains Gluten Free Grains
— Amaranth — Amaranth
— Arrowroot — Arrowroot
— Barley — Buckwheat/Kasha
— Buckwheat/Kasha — Corn
Corn
—
— Lentil or pea flours
— Lentil or pea flour
— Millet — Millet
— Nuts/seed meal or flours — Nuts/seed flours
— Oat — Potato
— Potato — Quinoa
— Quinoa — Rice
— Rice — Soy flour
— Rye — Tapioca
— Soy flour — Pre-made wheat/gluten free
— Tapioca flour mixes
— Pre-made wheat/gluten free
flour mixes

37. — 40-50% of infants with cow milk allergy, will also
have soy allergy. This is why soy formulas are not
recommended for infants with CMA
— Soy can be found in most shortenings, margarines,
vegetable sprays, Asian/oriental foods
— Soy protein is added to processed and commercial
foods to improve nutritional quality.
— Soy oils and soy lecithin usually safe- if very
sensitive, then avoid.
— Soy restricted diet alone should not compromise
nutrition intake

38. — Avoid eggs from all bird species
— Look for “egg” in baked goods, sauces, salad
dressings, breaded foods, pastas, candies,
desserts, used as binders as in meatloaf, used as
garnish, washed on bread, rolls, pies.
— Learn to cook with substitutes for egg as leavening
agent or as binders.
— Egg restricted diet alone should not compromise
nutritional intake.

39. — Peanuts are not related to Tree nuts. However,
there is high chance of cross-contamination.
— Refined peanut oil should be safe, but no guarantee,
so avoid it if high risk of anaphylaxis.
— Peanut or other nuts can be found in or cross
contaminated in candies, ice creams, some cheese
spreads.
— Seeds or seed butters may be alternatives.
— Peanut or tree nut restricted diets alone should not
compromise nutritional intake.

40. — Know the species you are allergic to. If allergic to
one type of shellfish, avoid all. Do not always need
to restrict other fish if allergic to one species.
— Fish oil likely to be contaminated with fish protein,
including Omega 3 fish oils, so avoid if allergic.
— Fish or shellfish may be in Asian, Thai, Chinese
foods, baked goods, cookies, candies, any food
containing gelatin. Be aware of Omega 3 fish oil
added to many foods for health benefits.
— Fish and Shellfish restricted diets alone should not
compromise nutritional intake.

41. — Do we need them?
— No-
— If taking 32 oz/day of “complete” formula or
— If eating wide variety of foods, from all food groups
— Maybe- if avoiding one major food group
— Probably- if avoiding two major food groups
— Definitely- if avoiding 3 or more food groups
— Everyone needs calcium/Vit D supplement-
if avoiding milk and not taking 32 oz/day fortified
milk substitute or ”complete” formula

42. — What kind?
— Generic might be ok if hypoallergenic
— Hypoallergenic are available-
— Costly
— Online: www.solacenutrition.com
— read labels carefully or ask pharmacist
— “Complete”- should have 100% of RDA, including iron and
zinc. Most won’t have much calcium.
— ½ to 1 tablet/day of Children’s chewable “complete”
— Gummies type are not “complete”
— May need additional nutrients, (Vit D, iron) if lab data
indicate deficiencies.

43. — Take in divided doses, no more than 500 mg at a
time, preferably with food.
— Vit D and Vit C improve absorption.
— High fiber diet decreases absorption
— Iron competes for absorption.
— Pills, chewable candies or liquid forms available.
— Calcium carbonate, calcium citrate
— Read labels carefully for allergen ingredients
— Usually <100 mg in children’s chewable vitamins.
— Calcium is not in infant/children’s liquid vitamins.

45. — FDA regulated
— Infant (0-12 months), Pediatric (1-10 year), Adult
— meets RDA for nutrients in ~1000 ml’s (33.3 oz) for ages
one year and older.
— Standard and special needs: For drinking or tube fed
— Care for just like food- re: handling, mixing, storing
— Powder, liquid concentrate, ready to feed
— Can Sustain life- provide “Total” nutrition

46. — Milk based:
— Infant: Enfamil, Similac, Good Start, generic
— Pediatric: Pediasure, Boost Kids Essential, Nutren Jr
— Adult: Ensure, Nutren, others
— Soy based:
— Infant: Prosobee, Isomil, generic
— Pediatric: Pediatric Soy Bright Beginnings
— Adult: Fibersource
— Partially hydrolyzed Milk:
— Infant: Nutramigen, Alimentum, Pregestimil
— Pediatric: Peptamen Jr, Vital Jr (new name: Pediasure Peptide)
— Adult: Peptamen

47. — Elemental formulas
— 100% amino acid, most simple form of protein
— Useful in milk, soy, or hydrolysate formula allergy
and intolerances, GERD, poor growth, EOE
— Total nutrition in ~33 oz/day
— Taste
— Varied flavors or unflavored for tube feeds
— Cost
— Very expensive. Medicaid and some insurance will cover,
(depending on diagnosis)
— Availability
— Not available in grocery stores
— Is available from WIC (1-5 years old), Homecare
pharmacies, mail order pharmacies, web based
companies, and thru manufacturers

48. — Abbott Nutrition: www.abbottnutrition.com
— Infant
— Infant Elecare: unflavored, powder, 20 kcal/oz
— Pediatric – 1-10 years
— Elecare Jr(new name): vanilla and unflavored, powder,
30 kcal/oz
— Nestle: www.nestlenutritionstore.com
— Pediatric – 1 year or older
— Pediatric Vivonex: unflavored, powder, 24 kcal/oz,
— Adult
— Vivonex plus: 30 kcal/oz, adult
— Tolerex: 30 kcal/oz, adult
— All unflavored, powder, used for tube feeds

49. — Mead Johnson: www.enfamil.com
— Infant
— Nutramigen AA: 20 kcal/oz, powder, unflavored,
— Nutricia North America: www.nutricia-na.com
— Infant
— Neocate with DHA and ARA: 20 kcal/oz, powder, unflav.
— Neocate nutra: corn based semi-solid food for >6 month
— Pediatric
— Neocate Jr: 30 kcal/oz, 3 flavors, powder
— EO28 Splash: 30 kcal/oz, 3 flavors, juice box

51. Sharlene Coombs, RD, CD, CSP, CNSD