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2 Paediatric Food Allergy Symposium The speaker had sole editorial control over the content in this slide deck. Any views, opinions or recommendations expressed in the slides are solely those of the speaker and do not necessarily represent those of Nutricia.

3 Heidi Ball Senior Specialist Dietitian Leicester Children s Allergy service

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6 Allergic reaction or repeatable symptoms which occur after ingestion of 3 or more staple foods (e.g. milk, wheat, egg, soya, nut, fish) Maybe IgE, Non IgE or a mixture

7 Common features How to structure a consultation in clinic (don t panic!) case example Preventing long term food allergy in this group (are we getting it wrong?)

8 Choice of milk substitute / nutrition Practical ideas for meals and special products when multiple allergens need to be avoided.

9 Based on our experience at Leicester Children s Allergy Clinics (multiple allergy clinic) Focus will be mainly on those infants/children with IgE mediated allergy

10 Rare (1 or 2 food allergens e.g. milk and egg, milk and soya or single nut is the norm) At more risk of nutritional problems More likely to have other medical symptoms (e.g. eczema, GI, rhinitus.) More likely to have persisting food allergies Sensitisation and SPT size is commonly higher Parental anxiety is high Take a long time in clinic (Why are they always the last patient on a busy overbooked clinic!!!)

11 Example referral I would be grateful if you could see this 8 month old Infant who has had several urticarial reactions with wheeze to cow s milk formula and 2 admissions to the emergency unit after a weaning food containing wheat and lentils. His mother is continuing to breast feed but is very anxious about feeding him as he also appears to react to carrots, potato, parsnip and all fruit. He also has significant eczema and is very unsettled. With thanks for your help.

12 problems outcome History IgE reactions,? Others? unsure diagnosis Eczema, GI Delayed solids, restricted solids Multiple food allergy child Clear diagnosis foods to avoid Relief from medical problems Less anxiety Parental anxiety Nutritional risk Optimise nutrition Treatment for reactions Consider reintroduction of allergens / prevention long term allergy

13 Skin prick allergy tests (more useful than specific IgE (less crossover, instant result) At FIRST appointment SPT only to foods causing IgE symptoms from history PLUS egg and peanut (and soya). Avoid SPT to fruits and veg unless clear IgE history e.g. Angiodema and hives after banana or symptoms to legumes with a known peanut reaction.

14 Foods with IgE symptoms Milk, Wheat, Lentil, Carrot Foods causing GI symptoms Pear (unsettled), apple (screaming), banana (diarrhoea), parsnip (constipated) Foods effecting eczema/itching Peach, Oats, potato Foods OK Rice, sweet potato (but stopped due to anxiety)

15 Skin prick test results Milk 9mm Wheat 5mm Lentil 3mm Carrot 4mm Egg 6mm (W) 4mm (Y) Peanut 3mm Soya 0mm

16 Start or maximise eczema treatment? Treatment for reflux? Treatment for constipation? Treatment rhinitis (older children) Assessment of feeding e.g. High volume breast feeding, maternal diet (allergens), change to amino acid formula Parents briefed that not all symptoms are food allergy

17 Eczema itchy, moderate active eczema. Using Diprobase emollient (reacts) and occasional hydrocortisone (reluctantly) G.I. frequent vomiting, colic, intermittent mucosy stool or constipation Mum on normal diet but not drinking milk.

18 Treatment Change emollient to Hydromol/white soft parafin 50:50 (maybe reacting to stabilizers in diprobase) 200g minimum per week. Eumovate (body) Hydrocortisone (face), Advice on safety/quantity/timing/prescription Maternal diet strict milk free Start Omeprazol or Ranitidine if not settled

19 Infant/child anxiety is driven by parental anxiety ACT EARLY!

20 Positive vs. Negative approach at diagnosis maybe important Your child has severe food allergies. It is probably best if you give only fresh home cooked foods one at a time as even a trace of food allergen may cause life threatening anaphylaxis. The good thing about food allergy is that the majority outgrow it. You will need to check labels carefully, but there are plenty of excellent alternatives and ideas we can give you.

21 I live in constant fear that he will eat something he shouldn t. We can t go to parties, we never eat out, and I ve given up my job. His diet is so limited and he s so fussy with food, if only he were normal Its not too much of a problem really, there are plenty of things he can have and he s very good at telling people what makes him poorly. We had a lovely time in Spain, although we did have to take some of his own snacks

22 Majority of children grow out of food allergy Expertise of the clinic/health professionals Anaphylaxis is rare Follow up and support is available Forget about ideals of perfect weaning Take 1 week at a time Reassure about weight/growth Ask about anxieties

23 Ideally children with multiple food allergy should be seen by a dietitian (regularly) with experience in food allergy (as part of a team) All children should have naked/vest only Weights under 2 years and supine heights (plotted). Head circumference may also be useful when growth or nutrition is a concern

24 Question At this moment, is this child gaining weight and growing along an appropriate centile? Yes No Focus on also focus on Milk substitute Deficiencies (bloods) Foods to try Assessment/advice on Avoidance of feeding? Supplements Allergens Change milk formula Start multi vitamin (with iron and Vit D e.g. Well baby drops) early if BF and/or eczema Give one or two clear instructions to follow (written)

25 Scenario 1 - thriving along 25 th centile Mum strict milk free diet. Check plans to continue BF, suggest a substitute for future use Foods to try corn, chicken/lamb/fish, melon, swede, finger food (rice cakes) Basic advice on allergen avoidance e.g. Labels NOT long diet sheets, recipe books, support groups, advice on possible deficiencies etc

26 Scenario 2 weight fallen 25 th to 10 th, length 10 th to 3 rd Bloods Vit D and ferritin, measure H.C. (25 th ) Maternal milk free / change to AA substitute (mixing) assessment feeding Introduce a protein solid early and dairy free margarine Reassurance to reduce anxiety/positive approach

27 Continue breast feeding (with/without maternal exclusion + multivit) Extensively hydrolysed formula (less suitable if faltering growth, eczema/gi, anaphylaxis ) Soya formula (check SPT neg, possible non IgE reaction, peanut allergy cross overotherwise introduce, sometimes as flour first).

28 Amino Acid formula e.g. Neocate, Alfamino, PureAmino usually most suitable. Introducing flavour early in BF infants may be useful. Concentrate if volumes low or may need to add supplements (calogen, paediatric seravit) Continue for as long as possible (e.g. age 2+ if multiple allergen intolerance persists)

29 Flavoured amino acid follow on milk e.g. Neocate Active (blackcurrent), Neocate Advance (bananavanilla) and (from April 2017 Neocate Junior) from 1 year For multiple food allergy refusing/not tolerating other choices and nutritionally compromised, use at ¾ dilution from 10months (not approvedclinical judgement and monitoring required) Alternative milk drinks e.g. Coconut milk, oat milk??????????????????

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31 100ml Almond Milk = 95 ml Water, 1 ¾ Almonds, (3g Sugar), 1.2g salt, (Calc & Vits)

32 Nutrient (per 100ml) Breast /formula (AAF follow on Neocate Active) Cows Milk FF/SSK/SK Kcal 67/ / 46 /32 AMD 1 Alpro (Almond) AMD 2 Oatly (Oat) Protein (g) 1.8/ Fat (EFA) (g) /1.7/ x Sugar (g) Salt (g) Iron (mg) 1 / Riboflavin (mg) 0.07/ / Vit D (µg) 1.2/ 0.82 tr / Calcium (mg) 66/ / B12 / Vit A (µg) 0.2/56 0.1/ / / / 0 / AMD 3 Organic (Coconut)

33 Alternative milk drinks are suitable for infants with multiple allergy for the purposes of cooking/meal improvement BUT not as a nutritional drink

34 Why are children with multiple food allergy treated differently for allergen reintroduction?

35 Anxiety over repeat anaphylaxis (medical/parental) SPT often high Assumption that nuts will be highly allergic therefore best avoided Ongoing symptoms e.g. Eczema, G.I. make reintroduction impossible Feeding problems and multiple allergen exclusion = difficulties getting suitable challenge food Introducing food one at a time causes delay to introduction of other allergen (Waiting list for supervised challenges)

36 Consider early reintroduction (12months) of baked milk and baked egg (and wheat) at first appointment do you need to book challenge slots if waiting list? Urgent peanut challenge if SPT 2 6mm (supervised) or advice on early introduction of nuts

37 Case example Challenge to peanut (bamba) on ward. Negative challenge, advice on regular peanut ingestion (peanut allergy prevention/protein source) From 12 months: 1) Advice on home (or supervised) baked egg introduction using crumbs of wheat free bread and increasing 2) Supervised wheat challenge, continue small doses wheat or 2) Supervised baked milk challenge, continue dose of baked milk

38 Free from jam tarts (milk) Free from bread products (egg) Heavenly wafer wisps (milk) Schar GF rich tea (milk/egg)

39 1) Antihistamine 2) Action plan (+ for nursery) 3) (Occasionally) Adrenalin

40 problems outcome History IgE reactions,? Others? unsure diagnosis Eczema, GI Delayed solids, restricted solids Parental anxiety Nutritional risk Multiple food allergy child Clear diagnosis foods to avoid Relief from medical problems Less anxiety positive approach Optimise nutrition Treatment for reactions Consider reintroduction of allergens / prevention long term allergy

41 X3 per year (more if needed) 32 patients Maximum 10 patients per clinic 2 doctors (Allergy nurse, Specialist Dietitian, Derm nurse input) Blood tests (usually x1/year for multiple food restriction) Reserved challenge slots Food display 80% patients are under age 5

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43 6 week review Eczema 50% improved GI symptoms settled New foods (mixed with sweet potato/rice) = chicken, lamb, grape puree. Unsettled corn, urticaria melon (antihistamine). Negative peanut challenge eating peanut butter mixed with Neocate daily Appointment baked egg challenge (wheat free bread) Parental anxiety decreased, thriving Mum following MF diet (+ calcium) + Neocate

44 4 month review multiple food allergy clinic (telephone/ contact with dietitian/eczema nurse) Eating all meats, fish, rice, potato, all veg (except lentil & carrot), banana, berry fruits, soya flour, BF/AA formula, wheat free products containing baked egg Ideas for recipes, products, snacks Eczema still regular treatment Weight dropped, changed to AA follow on (Neocate Active)

45 8 month review multiple food allergy clinic Reacted at ¼ biscuit (wheat), continues daily dose SPT 5mm milk, 4mm egg W, 5mm wheat, 0 carrot 2mm lentil. Introduce carrot. Baked milk (wheat free) planned (passed) Eczema mild AA follow formula (soya milk=diarrhoea) - weight increased Parents coping well, NO feeding problems

46 Home made free from supermarket, health food store, internet Prescribable? Choice can be confusing, daunting (and expensive)

47 Early stage Baby rice - (Cow and Gate, Aptamil, Milupa, Ellas Kitchen) Rice+ - (e,g, strawb/rasp porridge, Neocate spoon) Pure Fruit Pots/pouches Home cooked fruit/vegetable/meat/fish purees. Baby rice cakes/organix corn snacks/kiddilicious wafers/oaty fruity bars Formula recipes

48 Later stage Cornflakes(soggy)/rice krispies(blended) Knorr stock cubes (diluted), soups, adapted family meals (roast dinners, diluted Dolmio bolognaise, coconut cream sauce), MF marg, blancmange / custard powder, jelly, tinned fruit

49 Pasta (many varieties e.g. Rice, corn, soya, buckwheat) Bread Warburtons GF wraps (rice,tapioca,carob,apple,xanthum gum, corn, pea) or - Bfree Pitta bread (rice, potato, corn, tapioca, buckwheat,bamboo,apple,quinoa, pea,guar) - EnerG rice/tapioca bread or Teff (?prescribable) - Orgran buckwheat or corn crispbread

50 Biscuits GFpink panther wafers (potato, maize, coconut oil, soya lecithin) - Schar Grissini GF bread sticks (potato, rice, maize, buckwheat) - Sunstart golden crunch (maize, coconut, rice, millet, potato) Flour/Mixes - Doves farm (rice, potato, tapioca, maize, buckwheat) or H/Barret single flours - Asda pastry mix (rice/tapioca), Isabels batter mix (rice/cassava) Nutribix sorghum?

51 Miscellaneous Youngs free from fish fingers (rice, corn,potato, maize) Asda free from salad cream (maize, mustard) Asda free from lasagne sauce (coconut,onion,pepper,nutmeg) KoKo yoghurt (coconut, strawberry, maize) or Xotic desserts (coconut, tapioca) Moo free (rice, cocoa) or Kinneton Just chocolate (cocoa, soya lecithin)

52 around the world supermarkets/stores Examples; Cassava flour, potato starch, FuFu flour (plantain), Poppadoms (lentil flour), plantain chips, chinese dumplings, rice crackers, polish bamba snack Care over labelling/traces

53 Language/cultural differences Infections/illness More food allergens identifies Feeding problems (normally as a result of unpleasant feeding experiences/parental anxiety) GP prescriptions Dietetic time Food product changes DNA / cancelled appointments