Nutritional Considerations in Food Allergy Patients. Liz Hudson MPH, RD

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1 Nutritional Considerations in Food Allergy Patients Liz Hudson MPH, RD

2 Objectives Brief overview on food allergy Food allergen labeling laws Nutritional implications Cow s milk allergy Discussion on non-ige mediated food allergies and their nutritional implications Food Protein Induced Enterocolitis (FPIES) Eosinophilic Esophagitis in pediatric population (EoE, EE)

3 Food Allergy Food allergy defined: an adverse health affect arising from a specific immune response that occurs reproducibly on exposure to a given food. NIAID (National Institute of Allergy and Infectious Diseases) Immunoglobulin E mediated (IgE) Non-immunoglobulin E mediated (non-ige)

4 Source: FARE Overview

5 Food Labeling Food Allergen Labeling Consumer Protection Act (FALCPA) requires food labels to clearly identify the source of ingredients derived from the following eight major food allergens in plain language: Milk Soy Wheat Egg Peanut Tree nut (the specific nut must be identified) Fish (the specific fish species must be identified) Shellfish (the specific species must be identified

6 FALCPA Major Allergens Milk Ingredients not covered by FALCPA Gluten containing grains aside from wheat Products that must comply with FALCPA Food products Products not covered by FALCPA Raw agricultural commodities such as meats, fruits, and vegetables Alcohol, spirits Egg Mollusks (clams, oyster, scallop) Dietary supplements Wheat All other potential Infant formulas Medications allergens sesame Soy Medical foods Cosmetics, soaps, lotions, shampoos, etc. Peanut Tree nuts Fish Shellfish Source: Groetch, M. Food Allergies: Dietary Management. Practical Gastroenterology. Novemeber 2013.

7 Precautionary Labeling Precautionary labeling is voluntary and includes statements such as: May contain. Might contain. Processed in facilities that also process. Manufactured on equipment that also manufactures. Manufactured in a facility that processes. Advisory Statements: Allergens may be present in foods with precautionary food allergen statements, so it is best to avoid packaged foods that have these warnings. Certain manufacturing practices, such as the use of shared storage containers and processing equipment can result in residue of allergenic foods accidentally getting into otherwise safe food products.

People allergic to foods not included in the top 8 allergens may need to call the

8 Guidance to Patients Ingredient Labels: Take care to read the entire ingredient list including any advisory statements such as contains or may contain. People allergic to foods not included in the top 8 allergens may need to call the manufacturer to know if ingredients labeled with non-specific terms such as spice or natural flavoring contain a food that should be avoided.

9 Nutritional Impact and Growth Concerns The US Food Allergy Guidelines recommend nutrition counseling and regular growth monitoring for all children with a food allergy Comprehensive dietary education should include: How to avoid specific allergens Guidance on how to appropriately substitute for the nutrients typically provided by the eliminated foods

10 Nutritional Impact and Growth Concerns Poor growth and inadequate nutrient intake by food allergy children have been demonstrated in studies, particularly in children avoiding milk and/or more than 1 food due to multiple food allergies

Establishing a diagnosis Establishing a diagnosis is crucial selfperceived food allergy rates are high and parental perceived food allergy had led to severe exclusion diets with nutritional

11 Establishing a diagnosis Establishing a diagnosis is crucial selfperceived food allergy rates are high and parental perceived food allergy had led to severe exclusion diets with nutritional consequences, including failure to thrive -Roesler TA, Barry PC, Bock SA. Factitious food allergy and failure to thrive. Archives of pediatrics & adolescent medicine. 1994; 148(11): Epub 1994/11/01. [PubMed: ] 8. -Rona, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: a metaanalysis. The Journal of allergy and clinical immunology. 2007; 120(3): Epub 2007/07/14. [PubMed: ]

intake Impacted by dietary inadequacies sooner and to a greater extent than

12 Growth Growth is a good indicator of the adequate provision of energy and protein intake in children Weight is considered a sensitive measure of energy intake Impacted by dietary inadequacies sooner and to a greater extent than height Protein inadequacy or chronic undernutrition can result is delayed linear growth

13 Discrepancies in Height Age-matched cross sectional study children with 2 or more food allergies were shorter based on height-for-age percentiles than those with one food allergy Children with CMA had lower height-for-age compared to population controls without CMA Also smaller compared to their expected growth based on parental size and sibling growth Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth.journal of the American Dietetic Association. 2002;102(11): Paganus A, Juntunen-Backman K, Savilahti E. Follow-up of nutritional status and dietary survey in children with cow's milk allergy. Acta Paediatr. 1992;81(6-7): Tiainen JM, Nuutinen OM, Kalavainen MP. Diet and nutritional status in children with cow's milk allergy. European journal of clinical nutrition. 1995;49(8):

14 Discrepancies in Height Flammarion et al: Cross sectional food allergic children who and matched non-food allergic controls Both groups had received nutrition counseling by a dietitian Energy, protein and calcium intake of children with food allergies met nutritional goals, and were similar to dietary intakes of control children Growth for the food-allergic kids was normal, but weight-for-age and height-for-age z score were significantly lower than controls Flammarion S, Santos C, Guimber D, Jouannic L, Thumerelle C, Gottrand F, et al. Diet and nutritional status of children with food allergies. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. 2011; 22(2):161 5.

15 Height differences: cause for concern? Are children not reaching their growth potential at risk for obesity later in life? A child who has recovered from medical illness or food restriction, but is stunted secondary to that period of chronic malnutrition These children are often at risk to then subsequently become overweight or obese Is there a longer term sequelae?

16 Nutritional Impact and Growth Concerns: Micronutrients Children with cow s milk allergy or multiple food allergies consumed less than recommended amounts of dietary calcium compared with children without cow s milk allergy and/or one food allergy 25% of RDA Children with food allergy are reported to have lower intakes of vitamins D and E, iron, calcium, and zinc certain nutrients may be at greater risk of inadequacy depending on the food being avoided. Jensen VB, Jorgensen IM, Rasmussen KB, Molgaard C, Prahl P. Bone mineral status in children with cow milk allergy. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. 2004;15(6):562 5.

17 Nutritional Impact and Growth Concerns Inadequate energy intake in children with food allergy on elimination diets has been demonstrated in numerous studies Potential growth difference highlights the need to make every effort to optimize nutrition Source: Groetch, M. Food Allergies: Dietary Management. Practical Gastroenterology. Novemeber 2013.

18 Other Considerations Quality of Life Impact? Food elimination diets have been shown to impart financial and nutritional burdens, limit social activity and decrease quality of life

19 Cow s Milk Protein Allergy Cow s milk allergy (CMA) usually begins in infancy Affects 2-3% of the infant population At no time during the lifespan is nutrition more important Diet during infancy sets the stage for diet for the rest of the life span. Early feeding experiences affect feeding behaviors later on. Approximately 80-85% of children with cow s milk protein allergy will develop clinical tolerance in time

20 Cow s Milk Allergy Source of: Calcium, vitamin D, vitamin A, phosphorus, riboflavin, pantothenic acid, vitamin B12 Also protein and fat! Toddlers and young children require 30-40% of calories from fat Alternative sources of these nutrients must be found in the diet

21 Nutrition Comparison of Milk Alternatives Nutrient Profile Cow s Milk Soy Milk (Original) Soy Milk (vanilla) Almond Milk Almond Milk (vanilla) Almond Milk (chocolate) Rice Milk Rice Milk (vanilla) Coconut Milk Oat Milk Hemp Milk Pea protein based Milk (Ripple ) Calories per 8 oz Protein (grams) per 8 oz Fat (grams) per 8 oz Calcium (mg) per 8 oz Vitamin D (IU) per 8 oz ~

22 DRACMA The World Allergy Organization Diagnosis and Rationale for Action against Cow s Milk Allergy (DRACMA) Provide international guidance and management tools for practitioners working with patients with CMA Recommend children with CMA remain on a milk substitute (breast milk or formula) until 2 years of age to meet nutritional needs

23 Infant Formulas for cow s milk allergy or milk/soy FPIES Food Allergy Symptoms Low risk of anaphylaxis High risk of anaphylaxis Allergic proctocolitis or Food protein-induced enterocolitis syndrome (FPIES) Eosinophilic esophagitis First Choice Formula Recommendation Extensively hydrolyzed casein (Alimentum or Nutramigen) Amino acid based (Elecare or Neocate) Extensively hydrolyzed casein (Alimentum or Nutramigen)* Amino acid based (Elecare or Neocate) Second Choice Formula Recommendation May consider soy after 6 months Amino acid based (Elecare or Neocate) Extensively hydrolyzed casein (Alimentum or Nutramigen) Amino acid based (Elecare or Neocate) Groetch, M. (2013, November). Food Allergies: Dietary Management. Nutrition Issues in Gastroenterology, Series #123.

Nutrient Alternatives Protein: Beans, fish, meat, poultry, soy, seeds, peanut butter, nuts, eggs Fat: Avocado, oils, dairy-free butter and margarines, nuts, seeds,

alternative milks (soy, rice, coconut, almond, etc), calcium fortified orange juice, salmon, almonds, tofu, dark greens, orange, broccoli, white beans, sweet potato

24 Nutrient Alternatives Protein: Beans, fish, meat, poultry, soy, seeds, peanut butter, nuts, eggs Fat: Avocado, oils, dairy-free butter and margarines, nuts, seeds, meats, mayonnaise and salad dressing, nut butters, cream of coconut Vitamin A: Carrots, dark greens, pumpkin, sweet potatoes, winter squash Calcium: Calcium fortified alternative milks (soy, rice, coconut, almond, etc), calcium fortified orange juice, salmon, almonds, tofu, dark greens, orange, broccoli, white beans, sweet potato Vitamin D: Salmon, canned tuna and sardines, egg yolks, fortified milk alternatives and juices Phosphorus: Beans, biscuits, pancakes, waffles, whole wheat bread, bran cereal, nuts

25 Wheat allergy Most common grain used in western diets and the most common grain allergy Whole and enriched grains complex carbohydrates, thiamin, niacin, riboflavin, and iron Whole wheat provides fiber, magnesium, and B6 Enriched with folic acid

26 Nutrient dense alternative grains for Almond meal Arrowroot Barley Buckwheat Chickpea flour Corn Fava bean flour Flaxseed meal Millet wheat allergy Oat Potato starch Quinoa Rice Rye Sorghum Soy flour Tapioca Teff

Nutritional considerations: wheat allergy

27 Nutritional considerations: wheat allergy B-vitamins: Enriched rice, corn, oat cereals. Iron: Instant grits, instant oatmeal, white rice, lentils, white beans, spinach, beef, soy milk, almonds. Fiber: Beans, pears, quinoa, baked potato with skin, berries, peas, apple, dates.

28 Food Allergy Food allergy defined: an adverse health affect arising from a specific immune response that occurs reproducibly on exposure to a given food. NIAID (National Institute of Allergy and Infectious Diseases) Immunoglobulin E mediated (IgE) Non-immunoglobulin E mediated (non-ige)

29 Risk, Testing Modalities, and Treatments Henry, M. Nutrition Guidelines for treatment of children with eosinophilic esophagitis. Practical Gastroenterology. June 2014.

30 Non-IgE Mediated Food Allergic Disorders In general, affect skin and/or gastrointestinal tract and are delayed in onset

31 Food Protein Induced Enterocolitis FPIES Delayed immune reaction in the gastrointestinal system, usually diagnosed in infants and young children Reactions are delayed usually occur ~2 hours after ingestion of the causative food Repetitive, Profuse vomiting and/or diarrhea, lethargy Can be severe and lead to dehydration and shock Diagnosis is made on the basis of clinical history, reported symptoms, physical exam There is no skin test or blood test available to help diagnose FPIES

32 FPIES: Age of Diagnosis FPIES to cow s milk or soy is often diagnosed in early infancy, usually within days to weeks after formula is introduced Uncommon in exclusively breast fed infants, until formula or foods are started MILK is the most common liquid trigger of FPIES worldwide Solid food FPIES is usually diagnosed later, between the ages of 4-12 months when these foods are first introduced RICE is the most common solid food trigger in the US

33 Not well understood Pathogenesis

34 Acute vs. Chronic FPIES Source: Mane, SK. Bahna SL. Clinical manifestations of food protein-induced enterocolitis syndrome. Curr Opin Allergy Clin Immunol Jun; 14(3):

35 Management FPIES is commonly misdiagnosed as viral gastroenteritis. Acute Management: IV hydration, possibly medication Prevention of recurrence: Food avoidance Food challenges when appropriate Ensure adequate nutrition

36 Most Common Triggers The most common FPIES food triggers are cow s milk, soy, rice and oats, but any food can cause FPIES symptoms.

Most Common Triggers Slide courtesy of Dr. Matthew Greenhawt Leonard SA and Nowak Wegrzyn A. Ann Allergy Asthma Immunol 2011; 107: 95-101 Katz Y et al.

37 Most Common Triggers Slide courtesy of Dr. Matthew Greenhawt Leonard SA and Nowak Wegrzyn A. Ann Allergy Asthma Immunol 2011; 107: Katz Y et al. J Allergy Clin Immunol 2011: 127: Mehr S et al. Pediatrics 2009; 123: e Nowak Wegrzyn A et al. Pediatrics 2003; 111: Sopo S et al. Clin Exp Allergy 2012; 42: Ruffner et al. J Allergy Clin Immunol: In Practice; 2013; 1: 343-9

38 Infant Formulas for cow s milk allergy or milk/soy FPIES Food Allergy Symptoms Low risk of anaphylaxis High risk of anaphylaxis Allergic proctocolitis or Food protein-induced enterocolitis syndrome (FPIES) Eosinophilic esophagitis First Choice Formula Recommendation Extensively hydrolyzed casein (Alimentum or Nutramigen) Amino acid based (Elecare or Neocate) Extensively hydrolyzed casein (Alimentum or Nutramigen)* Amino acid based (Elecare or Neocate) Second Choice Formula Recommendation Amino acid based (Elecare or Neocate) Extensively hydrolyzed casein (Alimentum or Nutramigen) Amino acid based (Elecare or Neocate) Groetch, M. (2013, November). Food Allergies: Dietary Management. Nutrition Issues in Gastroenterology, Series #123.

Breastfeeding considerations Infant with FPIES can usually continue breastfeeding without difficulty and should not require maternal dietary avoidance of the allergen The AAP recommends that

39 Breastfeeding considerations Infant with FPIES can usually continue breastfeeding without difficulty and should not require maternal dietary avoidance of the allergen The AAP recommends that exclusively and partially breastfed infants receive 1 mg iron per kg per day starting at 4 months of age until ironcontaining complementary foods have been introduced to account for infants born with low iron stores Source: American Academy of Pediatrics

40 Nutritional Implications The more foods that need to be avoided, the greater the risk that the nutritional quality of the diet is impacted. FPIES usually begins in infancy: At no time during the lifespan is nutrition more important. Diet during infancy sets the stage for diet for the rest of the life span. Early feeding experiences affect feeding behaviors later on.

41 Food Introduction Infants with cow s milk or soy FPIES, have a greater chance of developing solid food FPIES most commonly to rice and other grains Grain avoidance is recommended, and fruits and vegetables are encouraged Tolerance to a food from a high risk group is often associated with an increased likelihood of tolerating other foods in that group

42 What to avoid once a diagnosis is made Milk Soy Grains (wheat, barley, rice, corn, oat) Poultry (chicken and turkey) Some beans (green peas, lentils) Others: sweet potato, squash, banana

43 Food Introduction: What can they eat? Usually start with age appropriate fruits, vegetables, and meats. Single-ingredient foods should be introduced one-at-atime, for at least 1 week* before trying another food Iron, calcium: Dark green vegetable (spinach, broccoli, kale) Vitamin A, C: Orange/yellow fruit, vegetable (carrot, papaya, apricot, mango) Iron, B-vitamins: Lamb, beef, pork Fat avocado, coconut, oils B-vitamins, fiber: Quinoa, millet

44 Other Considerations May require iron and vitamin D supplementation Feeding development and oral aversions: Feeding Texture Ideas: Thin puree Thick puree Mashed with lumps and bumps Soft cooked for finger foods Fried to crispy texture

45 FPIES FPIES can be challenging and very stressful for parents, nutrition and developmental needs can be met, even on the most limited diets Most children outgrow FPIES by age 3-4 Push for food challenges! cs/allergy/fpieshandout.pdf

Eosinophilic Esophagitis Eosinophilic Esophagitis (EoE) is a chronic immune-/antigen-mediated disease characterized by clinical symptoms and histological

46 Eosinophilic Esophagitis Eosinophilic Esophagitis (EoE) is a chronic immune-/antigen-mediated disease characterized by clinical symptoms and histological changes induced by environmental and/or dietary triggers. Dietary intervention for EoE include food eliminations: elemental diet an empiric approach and a tailored diet

47 Eosinophilic Esophagitis: Epidemiology First described in the 1970 s, however poorly recognized until the late 1990 s. May be regional variation higher prevalence in northeastern states and lower prevalence in western states. The diagnosis also appears to be more common in urban as opposed to rural settings. Prevalence within the United States may also differ between climate zones higher prevalence in cold and arid zones as compared with the tropical zones -Spergel JM, Book WM, Mays E, et al. Variation in prevalence, diagnostic criteria, and initial management options for eosinophilic gastrointestinal diseases in the United States. J Pediatr Gastroenterol Nutr 2011; 52:300. -Hurrell JM, Genta RM, Dellon ES. Prevalence of esophageal eosinophilia varies by climate zone in the United States. Am J Gastroenterol 2012; 107:698. -Greenhawt, M. et al. The management of Eosinophilic Esophagitis. J Allergy Clin. Immunol: In Practice. July/August 2013.

48 Pathophysiology Allergic mechanism is poorly understood Likely both IgE-mediated and non-ige mediated processes involved Environmental allergies are also a potential component

49 Eosinophilic Esophagitis Source: Greenhawt, M. et al. The management of Eosinophilic Esophagitis. J Allergy Clin. Immunol: In Practice. July/August 2013.

50 EoE: Management Steroid therapy: swallowed budesonide Acid suppression Dietary management

51 Dietary Management: 3 approaches Elemental dietary therapy Targeted dietary elimination Empiric dietary elimination

52 Elemental Diet Approach Elemental formula is sole source of nutrition Largest study 97% response rate (histological and symptomatic resolution) Likely not a good approach in older children, teens and adults Why? No long-term studies on effectiveness, or impact on quality of life

53 Targeted Dietary Elimination Most common approach in our clinic Specific foods are avoided on the basis of food allergy testing Milk Egg Soy Wheat Peanut Corn Beef Chicken Rice Potato Pork

54 Advantages/disadvantages of a targeted approach Can help preserve nutrition and diet normalcy by avoiding mass food avoidance The skin test and patch test results can help guide foods being added back into the diet Pediatric data Poor reliability of certain food tests Patch test results are subjective

55 Empiric Dietary Elimination Is usually done with or without allergy testing, and is the usual therapy used in most adult EoE patients. Six food elimination Milk, egg, wheat, soy, peanut/tree nut, fish/shellfish More of a movement toward a four food elimination diet Milk, egg, wheat, soy

56 Nutrition Risks Associated with EoE Source: Henry M. Nutrition Guidelines for Treatment of Children with Eosinophilic Esophagitis. Practical Gastroenterology. June 2014.

57 Role of the RD A registered dietitian is essential in this population in assessing growth, micronutrient intake, providing guidance to increase compliance and providing appropriate substitutions for implementing any elimination diet. An understanding of the typical presentations in patients with EoE will help determine nutrition risk and target evaluation. Assessment of baseline nutritional status May have signs and symptoms of nutritional inadequacy at diagnosis or before beginning and elimination diet. Poor growth, nutrient deficiencies, and feeding difficulties may worsen with restrictions in the diet. Education and regular follow-up are key to treating the patient with EoE. Patient compliance with medications and diet Source: Groetch, M. (2013, November). Food Allergies: Dietary Management. Nutrition Issues in Gastroenterology, Series #123.

Nutritional Management of EoE patient Diagnosis: Evaluate pre-diagnosis diet Food groups and variety Protein, energy, vitamin/mineral intake Feeding difficulties or behavioral compensations Weight

58 Nutritional Management of EoE patient Diagnosis: Evaluate pre-diagnosis diet Food groups and variety Protein, energy, vitamin/mineral intake Feeding difficulties or behavioral compensations Weight gain and growth Treatment: Education and Counseling Education on food eliminations Recommendations on substitutions to still meet nutrition needs Adjusting cooking methods when texture is a challenge Identification of vitamin/mineral supplementation Maintenance: Evaluate diet maintenance Review current diet Help determine food re-introduction Source: Groetch, M. (2013, November). Food Allergies: Dietary Management. Nutrition Issues in Gastroenterology, Series #123.

59 Feeding skills and/or maladaptive feeding behaviors Children with food allergies may experience Food aversion Food refusal Food neophobia Anxiety around eating in general Can lead to inadequate nutrient intake and is a problem in IgE-mediated and non-ige mediated food allergies

60 Maladaptive feeding behaviors Limiting diet to liquid or pureed foods Refusing to eat solids after previously eating them Studies have shown children with eosinophilic gastrointestinal disorders have significantly more feeding behavioral problems than healthy controls

61 Maladaptive feeding behaviors One study found that 16.5% of children with eosinophilic gastrointestinal disorders had significant feeding dysfunction (no co-morbid conditions present that may effect feeding) Of these, 94% had learned maladaptive behavior such as food refusal, low volume and variety of intake, grazing and spitting food out risks for undernutrition Mukkada VA, Haas A, Maune NC, Capocelli KE, Henry M, Gilman N, et al. Feeding dysfunction in children with eosinophilic gastrointestinal diseases. Pediatrics. 2010; 126(3):e672 7.

62 Atopic Dermatitis Partially hydrolyzed whey formulas and extensively hydrolyzed casein formulas may lower an infant s risk of developing allergies in particular skin allergies like atopic dermatitis If formula is necessary, these may be helpful especially if mom or siblings have a history of allergy Fleischer DM, Spergel JM, Assa ad AH, Pongracic. J Allergy Clin Immunol: In Practice 2013;1:29-36.

63 AAAAI Guidelines Recent evidence suggests there is no reason to delay introduction of highly allergenic foods beyond 4-6 months, delaying may increase risk for developing allergies Fleischer DM, Spergel JM, Assad AH, Pongracic. J Allergy Clin Immunol: In Practice 2013;1:29-36.

What s happening in Food Allergy LEAP study (Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy (Learning Early About Peanut )): Randomized controlled trial of high-risk

64 What s happening in Food Allergy LEAP study (Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy (Learning Early About Peanut )): Randomized controlled trial of high-risk infants (4-11 months) randomized to consume peanut at least 3 times per week or to completely avoid peanut for the first five years of life 17.2% of peanut avoidance group developed peanut allergy compared to 3.2% in the peanut consumption group

65 Introducing Highly Allergenic Foods in Babies The AAP recommends the introduction of complementary foods until the infant is at least 4 months old Exclusive breast-feeding is preferred until 6 months

66 Introducing Highly Allergenic Foods in Babies Introduce highly allergenic foods after other solid foods have been fed and tolerated Introduce them for the first time at home as opposed to at a restaurant or at day care If no reaction occurs, then gradually increase the amount at a rate of one new food every 3-5 days

Pediatric Food Allergies: Physician and Parent. Robert Anderson MD Rachel Anderson Syracuse, NY March 3, 2018

Pediatric Food Allergies: Physician and Parent Robert Anderson MD Rachel Anderson Syracuse, NY March 3, 2018 Learning Objectives Identify risk factors for food allergies Identify clinical manifestations