This document provides information for dietitians on managing food allergies in children. It discusses competencies including understanding trigger foods and growth requirements. It outlines advising patients on dietary plans, monitoring growth, and ensuring nutritional needs are met. The document also covers food labelling laws, common allergens, developing care plans for parents, and addressing quality of life issues.

1. Food Allergy Solving the puzzle: a Dietetic perspective. Ruth Charles, Paediatric Dietitian, www.NutriKids.ie

2. Competencies adapted from care pathway Food Allergy in Children 2011 Local implementation Multidisciplinary team Creating networks Know: what foods are likely to contain trigger foods. clinically relevant cross-reactivities and co-reactivities appropriate nutritional requirements for children at different ages signs and symptoms of faltering growth Be able to: advise on appropriate dietary exclusion and alternatives including practical, individualised cultural and age appropriate advice advise on appropriate avoidance of non food triggers (e.g. cosmetics and toiletries) ensure nutritional sufficiency in the context of dietary restrictions during different stages of childhood monitor growth accurately and assess nutritional intake revise dietary care plan to ensure that optimal growth and nutrition are maintained

3. The parent/carer/child needs to know: what foods and drinks to include & avoid how to interpret food labels alternative sources of nutrition to ensure adequate nutritional intake food avoidance if breastfeeding information on the most appropriate hypoallergenic formula or milk substitute if formula-fed information about the support available and details of how to contact support groups.

4. Food labelling & the law Legislation European Directives 2003/89/EC and 2006/142/EC Pre packaged foods All ingredients Presence of 14 recognised allergens

5. Recognised legislated allergens: Cereals containing gluten and products thereof Crustaceans and products thereof Eggs and products thereof Fish and products thereof Peanuts and products thereof Soybeans and products thereof Milk and products thereof (including lactose) Nuts i.e. almond, hazelnut, walnut, cashew, pecan nut, brazil nut, pistachio nut, macademia nut and queensland nut and products thereof Celery and products thereof Mustard and products thereof Sesame seeds and products thereof Sulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10 mg/litre expressed as SO2 Lupin and products thereof Molluscs and products thereof

6. Cows milk protein Lactoglobulin Casein or curd Milk solids Caseinates Non fat milk solids Hydrolysed Casein Whey Butter fat Whey solids Butter oil Whey syrup Lactose if severely allergic Hydrolysed whey protein Hydrolysed whey sugar/solids

7. Egg Albumen Globulin Lecithin – E322 Ovalbumen Livetin Ovomucin Ovoglobulin Pasteurised egg Ovovitellin Dried egg Vitellin Frozen egg Lysozyme Any ingredient which begins with ‘ovo’ or ‘ova’. Alternatives

8. Nut Peanut Ground nuts Ground pea Earth nuts Pinder Goober Monkey nuts Lupin needs to be avoided. Treenut Cashew Almond Brazil Hazelnut also called a Filbert or a Cob nut or Noisette Pistachio Pecan also called a Hickory nut Walnut Macadamia also called a Queensland or a Candle nut Chestnut Coconut Pine Nut

9. Label reading and ingredient interpretation : every label every time Food & drink Medicine Hand cream Cosmetics Shampoo Toothpaste

10. Food labelling issues No legal requirement to provide precautionary statement. Where provided: no criteria. Allergen thresholds Raw versus cooked: what temperature & for how long Frying, boil, roast Allergen in SPT assays versus food

11. EAACI Food Allergy & Anaphylaxis Meeting February 2011 Food Allergy & Anaphylaxis Alliance FAAA Criteria for use of precautionary statements Major allergens declared Simple language clear terms Consumer communication European Federation of Allergy & Airways Disease EFA Packaged and non packaged foods Abolish precautionary labelling Establish thresholds ( Taylor et al. Clin Exp Allergy. 34(5):689-95, 2004; Moneret-Vautrin. Curr Opin Allergy Clin Immunol. 2004 Jun;4(3):215-9) Working groups:ILSI Europe, Europrevall, CONGEN etc “ No label-no eat, no adrenalin – no eat”

12. Cross reactivities Sicherer, JACI December 2001.

13. Cross contamination awareness Slicing machines at Deli counters used for meat & cheese & .... Food preparation: chopping boards, knives, utensils, hands... Cooking vapours. Personal contact: lip, hand, skin “May contain traces of.....” not for those at risk of anaphylaxis

14. Risk management No child lives in a vacuum Be organised Emergency plan in all settings Avoid food sharing Have designated treat box Foods allowed list Clear information for all settings: daycare, school, clubs etc.

15. Nutrition for infants and children www.publichealth.hscni.net/ www.hse.ie www.fsai.ie

16. Nutrition requirements for children Adapted from Recommended Dietary Allowances for Ireland 1999, Food Safety Authority of Ireland

17. Calcium requirements 0-12 months 525mg 1-3yrs 350mg 4-6yrs 450mg 7-10yrs 550mg Males 11-18yrs 1000mg Females 11-28 yrs 800mg Breast feeding +500mg Vitamin D3 requirement 0-12 months5µg/200 i.u.

18. Faltering growth & food allergy Failure to grow at the expected rate: Height and weight velocity are the most sensitive indicators that energy requirements are being met Inappropriately restricted diets Associated asthma, chronic skin infections Appropriate centile reference charts

19. Poor parallel centiles - centile position falls, continued growth parallel to the 0.4 centile for weight and height. This occurs when children adapt to the abnormal situation of poor nutrition and the situation becomes chronic. Height and weight centiles markedly discrepant -where discrepancies in the centile ranking occur . Most children will have weight centile no more than 1 -2 centile spaces below their height. Family pattern discrepant - marked discrepancies from the parents and other family members attained height centiles. Retrospective rise - improvement in the child's centile position when nutrition is improved. Saw tooth - dipping. Weight goes up and down, crossing and recrossing centile positions.

20. Rough Ca2+ (100mg) ready reckoner dairy free 6-7oz/200ml Infant formula 3-4oz/100ml Calcium enriched soy/rice/oat milk 1oz/30g Soya cheese (hard, melting variety) 6oz/180g Soya cheese (hard, non-melting variety) 4oz/125g Soya yoghurt 3-4oz/100ml Calcium fortified orange juice 1oz/30g Sardines (tinned – where bones eaten) 1oz/30g Tofu 3oz/90g Spinach 2 Heaped tablespoons red kidney beans 1 large orange Half large tin baked beans 7oz/200g Dark green vegetables 1oz/30g Breakfast cereal 3 slices White bread / whole meal bread

21. Vitamin D rough ready reckoner

22. “Free from..” child friendly supplements Calcium (titrate dose to requirement) Calcichew (500mg carbonate) - Shire Sandocal 400 (400mg lactate gluconate & carbonate,effervescent) – Novartis Vitamin D3 Abidec vitamin D3: 5 drops-Chefaro Babyvit D3 : 2 drops-Shield Baby D : 0.2ml dropper-KoRa Healthcare

23. “ Free from...” child friendly supplements Calcium & D3 combined (titrate dose to requirement) Calcichew D3 forté (Shire) 500mg/10ug Calvidin chewable (Rottapharm) 600mg/10ug Ideos chewable (Helsinn Birex) 500mg/10ug Calcium & Vitamin D effervescent (Boots Healthcare) Osteocare Liquid (Vitabiotics) per 5 ml 150mg/1.9ug +Mg & Zn Osteocare Fizz (Vitabiotics) per tab 200mg/1.25ug + Mg Zn Cu Mn Se Vit C Multivitamin (titrate dose to requirement) Vivioptal Junior-Dr. Mann Pharma

24. Nutrient requirements from birth

25. Choosing the appropriate formula – reference guide fromDRACMA recommendations 2010

26. Cow’s Milk Alternatives > 6months Soy formula > 2 years (main drink) Calcium fortified cartoned soy/pea/oat/almond milk (Ca fortified rice milk >4.5years)

27. Nutrient requirements: Weaning

30. Quality of family life issues

31. Joe Bloggs DOB: xx/xx/xx Valid for dates: xx/xx/-xx/xx/ Check all labels for Milk/Egg/Nut For spread use: Granose For milk use: Alpro Soya Breakfast Weetabix/porridge/ready brek/rice krispies/cornflakes + milk Grilled rasher + Denny traditional sausage Brennans High Fibre Bran bread + spread Lunch Potato mashed with spread/rice/pasta drizzled in olive oil Carrot and parsnip/corn/peas/broccoli Grilled Chicken breast pieces/roast chopped meat/boneless salmon…… Tea Heinz baked beans on Brennans bread toast Soup and Brennans High Fibre Bran bread Sheese & tuna pasta bake Drinks Water/ milk/pure fruit juice diluted Snacks Seedless orange/Apple pieces/banana/stewed fruit/pineapple chunks/seedless grapes Carrot/celery/cucumber sticks Sheese toastie on Brennans Bread Sheese cubes Brennans bread toast Hummous and Tesco breadsticks Treats Kinnerton dairy free choc buttons/Jelly babies / Tayto snax/chipstix

32. Recipes:adapt or specialised

33. The Treat Box

34. Links

35. Thank you