Presented at the first meeting of ISPEN in Dublin

1. Food allergy in infancy and beyond
A practical management
approach
Ruth Charles

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.
www.nutrikids.ie

3. 2011
Irish Food Allergy Network (IFAN) care pathways for milk,
egg, nut & others.
In development 2011/2012
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

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.
www.nutrikids.ie

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.
www.nutrikids.ie

6. Growth
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

7. RAST at age 2, repeated age 4
Milk +1 +2
Egg +1 +3
Peanut +2 +2
Soy +2 +3
• Elimination of all these foods and derivatives
recommended since age 2.
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

8. Food intake
8 am Breakfast: 2pm Playgroup afternoon snack
½ Ricekrispies/cornflakes Banana/rice cake.
+ rice milk Carton juice
½ slice toast and margarine 4pm Playgroup tea
Cup of tea As at lunch.
11amPlaygroup snack: Carton juice.
1 Ricecake & jam Home by 6pm
Carton juice Eats crisps/jellies/biscuits.
12.30 Playgroup Lunch Diluted squash 800ml/day.
Sent from home or Bed 9-10pm
12 month baby jar.
Carton juice. Est. 1100kcals, 21g protein
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

9. What do you do?
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

10. Suggested issues & priorities
Symptomatic 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.
www.nutrikids.ie

11. Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

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.
www.nutrikids.ie

13. Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

14. Allergic March
Temporal pattern of progression from eczema to allergic rhinitis and asthma.
Ker 2009
Mechanisms by which allergen exposure through the epidermis can initiate systemic
allergy and predispose individuals to atopic dermatitis, allergic rhinitis, and asthma
have become clearer in recent years. Spergel 2010.
GI allergic disease
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

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.
www.nutrikids.ie

16. Energy requirements
Approx 300kcal energy deficit for normal growth requirements
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

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.
www.nutrikids.ie

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.
www.nutrikids.ie

19. Anorexia
• Find & treat cause if possible
– Infection
– Stress
• Consider GI co-morbidities
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

20. GI allergic disease, NICE UK 2011
Consider the possibility of food allergy in children and young people
whose symptoms do not respond adequately to treatment for:
atopic eczema
gastro-oesophageal reflux disease
chronic gastrointestinal symptoms, including chronic constipation.
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

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.
www.nutrikids.ie

22. Bone health
• Supplement until milk tolerance is established
• Consider divided dose of calcium
• RDA for age
Ruth Charles, Paediatric Dietitian.
www.nutrikids.ie

23. Allergy testing
RAST rating IgE level (KU/L) comment
• RAST unhelpful & 0 < 0.35
ABSENT OR
UNDETECTABLE
ALLERGEN SPECIFIC IgE
unspecific 1 0.35 - 0.69
LOW LEVEL OF
ALLERGEN SPECIFIC IgE
Milk +1 +2
MODERATE LEVEL OF
2 0.70 - 3.49
Egg +1 +3 ALLERGEN SPECIFIC IgE
Peanut +2 +3 3 3.50 - 17.49
HIGH LEVEL OF
ALLERGEN SPECIFIC IgE
Soy +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.
www.nutrikids.ie

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.
www.nutrikids.ie

25. Recommended interpretation of food allergen–specific IgE levels
(kUA/L) in the diagnosis of food allergy
Sampson 2000
Egg Milk Peanut Fish Soy Wheat
Reactive if ≥ 7 15 14 20 65 80
(no challenge
necessary)
Possibly 30† 26† ↓ Probability
reactive
(physician
of
challenge*) reaction
Unlikely 0.35 0.35 0.35 0.35 0.35 0.35
reactive if <
(home
challenge*)
*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.
www.nutrikids.ie

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.
www.nutrikids.ie