Food allergy in children:solving the puzzle


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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
  • Food allergy in children:solving the puzzle

    1. 1. Food Allergy <br />Solving the puzzle: a Dietetic perspective.<br />Ruth Charles, Paediatric Dietitian,<br />
    2. 2. Competencies adapted from care pathway Food Allergy in Children 2011<br />Local implementation Multidisciplinary team Creating networks<br />Know:<br />what foods are likely to contain trigger foods. <br /> clinically relevant cross-reactivities and co-reactivities<br /> appropriate nutritional requirements for children at different ages <br />signs and symptoms of faltering growth <br />Be able to:<br />advise on appropriate dietary exclusion and alternatives including practical, individualised cultural and age appropriate advice <br />advise on appropriate avoidance of non food triggers (e.g. cosmetics and toiletries) <br />ensure nutritional sufficiency in the context of dietary restrictions during different stages of childhood <br />monitor growth accurately and assess nutritional intake <br />revise dietary care plan to ensure that optimal growth and nutrition are maintained <br />
    3. 3. The parent/carer/child needs to know:<br />what foods and drinks to include & avoid<br />how to interpret food labels<br />alternative sources of nutrition to ensure adequate nutritional intake<br />food avoidance if breastfeeding <br />information on the most appropriate hypoallergenic formula or milk substitute if formula-fed<br />information about the support available and details of how to contact support groups.<br />
    4. 4. Food labelling & the law<br />Legislation European Directives 2003/89/EC and 2006/142/EC  <br />Pre packaged foods<br />All ingredients <br />Presence of 14 recognised allergens <br />
    5. 5. Recognised legislated allergens:<br />Cereals containing gluten and products thereof<br />Crustaceans and products thereof<br />Eggs and products thereof<br />Fish and products thereof<br />Peanuts and products thereof<br />Soybeans and products thereof<br />Milk and products thereof (including lactose)<br />Nuts i.e. almond, hazelnut, walnut, cashew, pecan nut, brazil nut, pistachio nut, macademia nut and queensland nut and products thereof<br />Celery and products thereof<br />Mustard and products thereof<br />Sesame seeds and products thereof<br />Sulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10 mg/litre expressed as SO2<br />Lupin and products thereof<br />Molluscs and products thereof<br />
    6. 6. Cows milk protein <br />Lactoglobulin Casein or curd<br />Milk solids Caseinates<br />Non fat milk solids Hydrolysed Casein<br />Whey Butter fat <br />Whey solids Butter oil<br />Whey syrup Lactose if severely allergic<br />Hydrolysed whey protein<br />Hydrolysed whey sugar/solids <br />
    7. 7. Egg <br />Albumen Globulin<br />Lecithin – E322 Ovalbumen<br />Livetin Ovomucin<br />Ovoglobulin Pasteurised egg <br />Ovovitellin Dried egg<br />Vitellin Frozen egg<br />Lysozyme<br />Any ingredient which begins with ‘ovo’ or ‘ova’.<br />Alternatives<br />
    8. 8. Nut <br />Peanut<br />Ground nuts<br />Ground pea<br />Earth nuts<br />Pinder<br />Goober<br />Monkey nuts<br />Lupin needs to be avoided. <br />Treenut<br />Cashew<br />Almond<br />Brazil<br />Hazelnut also called a Filbert or<br />a Cob nut or Noisette<br />Pistachio<br />Pecan also called a Hickory nut<br />Walnut<br />Macadamia also called a<br />Queensland or a Candle nut<br />Chestnut<br />Coconut <br />Pine Nut<br />
    9. 9. Label reading and ingredient interpretation : every label every time<br />Food & drink<br />Medicine<br />Hand cream<br />Cosmetics<br />Shampoo<br />Toothpaste<br />
    10. 10. Food labelling issues <br />No legal requirement to provide precautionary statement. Where provided: no criteria.<br />Allergen thresholds <br />Raw versus cooked:<br />what temperature & for how long<br />Frying, boil, roast  <br />Allergen in SPT assays versus food<br />
    11. 11. EAACI Food Allergy & Anaphylaxis Meeting February 2011<br />Food Allergy & Anaphylaxis Alliance FAAA<br />Criteria for use of precautionary statements<br />Major allergens declared<br />Simple language clear terms<br />Consumer communication <br />European Federation of Allergy & Airways Disease EFA<br />Packaged and non packaged foods<br />Abolish precautionary labelling<br />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<br />“ No label-no eat, no adrenalin – no eat”<br />
    12. 12. Cross reactivities<br />Sicherer, JACI December 2001.<br />
    13. 13. Cross contamination awareness <br />Slicing machines at Deli counters used for meat & cheese & ....<br />Food preparation: chopping boards, knives, utensils, hands...<br />Cooking vapours.<br />Personal contact: lip, hand, skin<br />“May contain traces of.....” <br />not for those at risk of anaphylaxis<br />
    14. 14. Risk management<br />No child lives in a vacuum<br />Be organised<br />Emergency plan in all settings<br />Avoid food sharing<br />Have designated treat box<br />Foods allowed list<br />Clear information for all settings: daycare, school, clubs etc.<br />
    15. 15. Nutrition for infants and children<br /><br /><br /><br />
    16. 16. Nutrition requirements for children<br />Adapted from Recommended Dietary Allowances for Ireland 1999, Food Safety Authority of Ireland<br />
    17. 17. Calcium requirements<br />0-12 months 525mg<br />1-3yrs 350mg <br />4-6yrs 450mg <br />7-10yrs 550mg <br />Males 11-18yrs 1000mg<br />Females 11-28 yrs 800mg<br />Breast feeding +500mg<br />Vitamin D3 requirement<br />0-12 months5µg/200 i.u.<br />
    18. 18. Faltering growth & food allergy<br />Failure to grow at the expected rate: <br />Height and weight velocity are the most <br />sensitive indicators that energy <br />requirements are being met<br />Inappropriately restricted diets<br />Associated asthma, chronic skin infections<br />Appropriate centile reference charts<br />
    19. 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.<br />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.<br />Family pattern discrepant - marked discrepancies from the parents and other family members attained height centiles.<br />Retrospective rise - improvement in the child's centile position when nutrition is improved. <br />Saw tooth - dipping. Weight goes up and down, crossing and recrossing centile positions. <br />
    20. 20. Rough Ca2+ (100mg) ready reckoner dairy free<br />6-7oz/200ml Infant formula <br />3-4oz/100ml Calcium enriched soy/rice/oat milk <br />1oz/30g Soya cheese (hard, melting variety) <br />6oz/180g Soya cheese (hard, non-melting variety) <br />4oz/125g Soya yoghurt <br />3-4oz/100ml Calcium fortified orange juice <br />1oz/30g Sardines (tinned – where bones eaten)<br />1oz/30g Tofu <br />3oz/90g Spinach <br />2 Heaped tablespoons red kidney beans <br />1 large orange <br />Half large tin baked beans <br />7oz/200g Dark green vegetables <br />1oz/30g Breakfast cereal<br />3 slices White bread / whole meal bread <br />
    21. 21. Vitamin D rough ready reckoner<br />
    22. 22. “Free from..” child friendly supplements <br />Calcium (titrate dose to requirement)<br />Calcichew (500mg carbonate) - Shire<br />Sandocal 400 (400mg lactate gluconate & <br />carbonate,effervescent) – Novartis<br />Vitamin D3<br />Abidec vitamin D3: 5 drops-Chefaro <br />Babyvit D3 : 2 drops-Shield<br />Baby D : 0.2ml dropper-KoRa Healthcare<br />
    23. 23. “ Free from...” child friendly supplements<br />Calcium & D3 combined (titrate dose to requirement)<br />Calcichew D3 forté (Shire) 500mg/10ug<br />Calvidin chewable (Rottapharm) 600mg/10ug<br />Ideos chewable (Helsinn Birex) 500mg/10ug<br />Calcium & Vitamin D effervescent (Boots Healthcare)<br />Osteocare Liquid (Vitabiotics) per 5 ml 150mg/1.9ug +Mg & Zn<br />Osteocare Fizz (Vitabiotics) per tab 200mg/1.25ug + Mg Zn Cu Mn Se Vit C<br />Multivitamin (titrate dose to requirement)<br />Vivioptal Junior-Dr. Mann Pharma<br />
    24. 24. Nutrient requirements from birth <br />
    25. 25. Choosing the appropriate formula – reference guide fromDRACMA recommendations 2010<br />
    26. 26. Cow’s Milk Alternatives<br />> 6months<br />Soy formula<br /> > 2 years (main drink)<br />Calcium fortified cartoned soy/pea/oat/almond milk<br />(Ca fortified rice milk >4.5years)<br />
    27. 27. Nutrient requirements: Weaning<br />
    28. 28.
    29. 29.
    30. 30. Quality of family life issues<br />
    31. 31. Joe Bloggs DOB: xx/xx/xx Valid for dates: xx/xx/-xx/xx/<br />Check all labels for Milk/Egg/Nut <br />For spread use: Granose<br />For milk use: Alpro Soya<br />Breakfast<br />Weetabix/porridge/ready brek/rice krispies/cornflakes + milk<br />Grilled rasher + Denny traditional sausage<br />Brennans High Fibre Bran bread + spread <br />Lunch<br />Potato mashed with spread/rice/pasta drizzled in olive oil<br />Carrot and parsnip/corn/peas/broccoli<br />Grilled Chicken breast pieces/roast chopped meat/boneless salmon……<br />Tea<br />Heinz baked beans on Brennans bread toast<br />Soup and Brennans High Fibre Bran bread<br />Sheese & tuna pasta bake<br />Drinks<br />Water/ milk/pure fruit juice diluted <br />Snacks<br />Seedless orange/Apple pieces/banana/stewed fruit/pineapple chunks/seedless grapes<br />Carrot/celery/cucumber sticks <br />Sheese toastie on Brennans Bread<br />Sheese cubes<br />Brennans bread toast <br />Hummous and Tesco breadsticks<br />Treats<br />Kinnerton dairy free choc buttons/Jelly babies /<br />Tayto snax/chipstix<br />
    32. 32. Recipes:adapt or specialised<br />
    33. 33. The Treat Box<br />
    34. 34. Links <br />
    35. 35. Thank you<br />