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Food allergy in children:solving the puzzle
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Food allergy in children:solving the puzzle


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


  • 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
    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
    Any ingredient which begins with ‘ovo’ or ‘ova’.
  • 8. Nut
    Ground nuts
    Ground pea
    Earth nuts
    Monkey nuts
    Lupin needs to be avoided.
    Hazelnut also called a Filbert or
    a Cob nut or Noisette
    Pecan also called a Hickory nut
    Macadamia also called a
    Queensland or a Candle nut
    Pine Nut
  • 9. Label reading and ingredient interpretation : every label every time
    Food & drink
    Hand cream
  • 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
  • 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
    Weetabix/porridge/ready brek/rice krispies/cornflakes + milk
    Grilled rasher + Denny traditional sausage
    Brennans High Fibre Bran bread + spread
    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……
    Heinz baked beans on Brennans bread toast
    Soup and Brennans High Fibre Bran bread
    Sheese & tuna pasta bake
    Water/ milk/pure fruit juice diluted
    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
    Kinnerton dairy free choc buttons/Jelly babies /
    Tayto snax/chipstix
  • 32. Recipes:adapt or specialised
  • 33. The Treat Box
  • 34. Links
  • 35. Thank you