Food Allergy In Infancy And Beyond


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Presented at the first meeting of ISPEN in Dublin

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  • Key issue is that if may contain foods have caused anaphylaxis
  • Food Allergy In Infancy And Beyond

    1. 1. Food allergy in infancy and beyond A practical management approach Ruth Charles
    2. 2. Food labelling & the law• Legislation European Directives 2003/89/EC and 2006/142/EC• Pre packaged foods• All ingredients• Presence of 14 recognised allergens Cereals containing gluten and products thereof Celery and products thereof Crustaceans and products thereof Mustard and products thereof Eggs and products thereof Sesame seeds and products thereof Fish and products thereof Sulphur dioxide and sulphites at concentrations of Milk and products thereof (including lactose) more than 10mg/kg or 10 mg/litre expressed as SO2 Nuts i.e. almond, hazelnut, walnut, cashew, Lupin and products thereof pecan nut, brazil nut, pistachio nut, macademia nut, Molluscs and products thereof queensland nut and products Soybeans and products thereof Peanuts and products thereof Ruth Charles, Paediatric Dietitian.
    3. 3. 2011Irish Food Allergy Network (IFAN) care pathways for milk,egg, nut & others.In development 2011/2012 Ruth Charles, Paediatric Dietitian.
    4. 4. Patient Z: first contact• Summer time• 4 year old girl, only child• Single mum, smoker• Living in caravan in granny’s garden Ruth Charles, Paediatric Dietitian.
    5. 5. Patient Z• Viral RTI’s increased frequency since age 2, onset of wheeze age 3• Rhinitis/hayfever: from age 3 • Active, congested • Sleep affected• Eczema from 6 weeks of age • Widespread • Actively oozing • Infected • Itchy, waking scratching• “Miserable”, pale, anorexia• Growth faltering• “RAST” available Ruth Charles, Paediatric Dietitian.
    6. 6. GrowthRuth Charles, Paediatric Dietitian.
    7. 7. RAST at age 2, repeated age 4Milk +1 +2Egg +1 +3Peanut +2 +2Soy +2 +3• Elimination of all these foods and derivatives recommended since age 2. Ruth Charles, Paediatric Dietitian.
    8. 8. Food intake8 am Breakfast: 2pm Playgroup afternoon snack½ Ricekrispies/cornflakes Banana/rice cake.+ rice milk Carton juice½ slice toast and margarine 4pm Playgroup teaCup of tea As at lunch.11amPlaygroup snack: Carton juice.1 Ricecake & jam Home by 6pmCarton juice Eats crisps/jellies/biscuits.12.30 Playgroup Lunch Diluted squash 800ml/day.Sent from home or Bed 9-10pm12 month baby jar.Carton juice. Est. 1100kcals, 21g protein Ruth Charles, Paediatric Dietitian.
    9. 9. What do you do? Ruth Charles, Paediatric Dietitian.
    10. 10. Suggested issues & prioritiesSymptomatic treatment: congestion, rhinitis, itch, infection. Atopic : “Allergic March” Plan for management of co-morbidities (including housing/smoking) Sleep Growth Food Allergy Ruth Charles, Paediatric Dietitian.
    11. 11. Ruth Charles, Paediatric Dietitian.
    12. 12. “reactions to food can only be diagnosed by a thorough diagnostic procedure, taking into account the patient’s history, the degree of sensitization and the clinical relevance of the sensitization”.Ruth Charles, Paediatric Dietitian.
    13. 13. Ruth Charles, Paediatric Dietitian.
    14. 14. Allergic MarchTemporal pattern of progression from eczema to allergic rhinitis and asthma.Ker 2009Mechanisms by which allergen exposure through the epidermis can initiate systemicallergy and predispose individuals to atopic dermatitis, allergic rhinitis, and asthmahave become clearer in recent years. Spergel 2010.GI allergic disease Ruth Charles, Paediatric Dietitian.
    15. 15. Growth & nutrition issues • Calcium • Phosphorous • Vitamin D Bone health • Magnesium • Oral & topical steroids Blood health • Haem iron • Tannin • B12 • Folate Calories • Appetite • Protein energy ratio • Dental health • Bowel function Ruth Charles, Paediatric Dietitian.
    16. 16. Energy requirementsApprox 300kcal energy deficit for normal growth requirements Ruth Charles, Paediatric Dietitian.
    17. 17. Patient Z: effect of atopy on metabolic rate Accelerated cell loss Infection Stress Catch –up ↑Cell ↑↑Metabolic growth turnover rate +normal requirements? Net energy cost ? Ruth Charles, Paediatric Dietitian.
    18. 18. Calories & energy• Consider protein : energy ratio• MUFA/PUFA cold oils added to lunch and dinner• Carbohydrate 6 times a day, portions as tolerated. – Fortified breads – Oat/wheat based cereals – Potatoes/pasta/couscous – Fructose/glucose• Supplementary FSMP• Address anorexia Ruth Charles, Paediatric Dietitian.
    19. 19. Anorexia• Find & treat cause if possible – Infection – Stress• Consider GI co-morbidities Ruth Charles, Paediatric Dietitian.
    20. 20. GI allergic disease, NICE UK 2011Consider the possibility of food allergy in children and young peoplewhose symptoms do not respond adequately to treatment for: atopic eczema gastro-oesophageal reflux disease chronic gastrointestinal symptoms, including chronic constipation. Ruth Charles, Paediatric Dietitian.
    21. 21. Blood health• Haem iron animal protein source 4 times a week – Beef, lamb, pork• Non-haem iron sources: fortified cereals consumed at same time as vitamin C source• Supplement if medically indicated Ruth Charles, Paediatric Dietitian.
    22. 22. Bone health• Supplement until milk tolerance is established• Consider divided dose of calcium• RDA for age Ruth Charles, Paediatric Dietitian.
    23. 23. Allergy testing RAST rating IgE level (KU/L) comment• RAST unhelpful & 0 < 0.35 ABSENT OR UNDETECTABLE ALLERGEN SPECIFIC IgEunspecific 1 0.35 - 0.69 LOW LEVEL OF ALLERGEN SPECIFIC IgEMilk +1 +2 MODERATE LEVEL OF 2 0.70 - 3.49Egg +1 +3 ALLERGEN SPECIFIC IgEPeanut +2 +3 3 3.50 - 17.49 HIGH LEVEL OF ALLERGEN SPECIFIC IgESoy +2 +3 VERY HIGH LEVEL OF 4 17.50 - 49.99 ALLERGEN SPECIFIC IgE VERY HIGH LEVEL OF 5 50.0 - 100.00 ALLERGEN SPECIFIC IgE EXTREMELY HIGH 6 > 100.00 LEVEL OF ALLERGEN SPECIFIC IgE Ruth Charles, Paediatric Dietitian.
    24. 24. Allergy Testing• EAACI/NICE/RCPCH: – complementary and alternative medicine (CAM) allergy tests: applied kinesiology, serum specific IgG, hair analysis and Vega tests have no place in the diagnosis and/or management of food allergy.• After allergy focused clinical history, serum specific IgE, skin tests, oral food challenges in those trained in their use and competent in their interpretation. Ruth Charles, Paediatric Dietitian.
    25. 25. Recommended interpretation of food allergen–specific IgE levels (kUA/L) in the diagnosis of food allergy Sampson 2000 Egg Milk Peanut Fish Soy WheatReactive if ≥ 7 15 14 20 65 80(no challengenecessary)Possibly 30† 26† ↓ Probabilityreactive(physician ofchallenge*) reactionUnlikely 0.35 0.35 0.35 0.35 0.35 0.35reactive if <(homechallenge*) *In patients with a strongly suggestive history of an IgE-mediated food allergic reaction, food challenges should be performed with physician supervision, regardless of food-specific IgE value. If the food-specific IgE level is less than 0.35 kUA/L and the skin prick test response is negative, the food challenge can be performed at home unless there is a compelling history of reactivity. Ruth Charles, Paediatric Dietitian.
    26. 26. ? Food Allergy ?• Prevalence of food allergy in this population is significantly higher than in the general population. EAACI 2008• Allergy focused clinical history – Ever had severe reaction to food? Describe any reaction. – Ever eaten milk, egg, nut, soy? – What happens when those foods are eaten? – need if any for testing.• Address nutrient deficiencies as indicated• Reintroduce as much food as possible.• Re-evaluate over time. Ruth Charles, Paediatric Dietitian.