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Food allergy in children:solving the puzzle

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Presented at the 7th Annual Nutricia Paediatric Nutrition Symposium, May 2011, Dublin.

Presented at the 7th Annual Nutricia Paediatric Nutrition Symposium, May 2011, Dublin.


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  • Key issue is that if may contain foods have caused anaphylaxis
  • MMR grown in chick embryoFlu vaccine residual amounts of egg proteins (≤ 1 mcg ovalbumin) Abidec contains peanut oil, deproteinated-no riskClarityn contains lactoseSingulair 10mg film coated contains lactose not paediatric 4mg chewable/oral granules 5mg chewable do not.
  • Raw versus boiled peanutsFrying or boiling peanuts, as practiced in China, appear to reduce the allergenicity of peanuts compared with the method of dry roasting IgE binding to Ara h 2 and Ara h 3 
  • Maria Said Anaphylaxis AustraliaWorldwide huge complex issue
  • Cannot eliminate all risk, have to manage itNo truly allergy free environment despite detergents, hot waterIn cases of anaphylaxis resulting from a food avoided need to think outside the box
  • Transcript

    • 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
    • 28.
    • 29.
    • 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

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