FEEDING THE ALLERGIC CHILD Berber Vlieg-Boerstra, RD PhD Senior research dietitian OLVG, Amsterdam University of Applied Sciences, Groningen Vlieg&Melse Dietitians, Practice for food allergy
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Agenda How to recognize food allergy Misperceptions / take the lead Allergy-focussed diet history: the cornerstone of diagnosis Red flags in diet history Pro-active dietary management, choosing the right hypoallergenic formula (if not breastfed)
How to recognize food allergy Classification Prevalence Symptoms Natural history Common food allergens
Types of adverse reactions to food Boyce JA et al. J Allergy Clin Immunol. 2010;126: S1 58
The allergic march (IgE mediated) CMA Adapted from www.londonallergy.com Symptoms often co-exist - Cow s Milk Allergy (CMA) is the first food allergy to develop - CMA co-exists with eczema, followed by asthma and hay fever - Not all CMA is outgrown by age 4 or 5
Cumulatieve incidence age 2 years: - IgE gemed. FA 2.6% (1.5-3.6%) - Non-IgE gemed. VA 2.4% (1.4-3.5%) - Hen s egg 2.7% (1.6-3.8%) - Cow s milk 2.4% (1.4-3.5%) - Peanut 0.7% (0.1-1.3%) - Soy 0.4% (0.0-0.8%) - Wheat 0.2% (0.0-0.5%) - Fish 0.1% (0.0-0.3%) Clin Transl Allergy. 2016 Jan 26;6:1. Immediate and delayed symptoms < 2 uur
Cow s milk allergy in European children: The Europrevall birth cohort Only immediate symptoms < 2 uur Schoemaker et al. Allergy 2015;70:963-972
Symptoms of immediate reactons to food Skin (rash, urticaria) Gastro- Intestinal dystress Food refusal, also in breastfed infants! Allergic Rhinoconjunctivitis Astma exacerbation Anaphylaxis
Symptoms of delayed reactons to food Atopic dermatitis Failure to thrive Excessive crying, (repeated) vomiting diarrhea (with mucus)
Peptides from mother s diet detected in breast milk Picariello et al. Funct Food 2016;7:3402-9
New manifestations of allergic disease Eosinophilic Esophagitis: allergic esophagus Infants and children: Failure to thrive, vomiting, food refusal, slow eaters Older children and adults: dysphagia, food impaction, dyspepsia
Natural history of food allergy Adapted from www.londonallergy.com
Food allergy Common allergens in infants/children Cow s milk Egg Soy Wheat Fish Peanuts Tree nuts Seeds Shell fish/sea food
Food allergens Common allergens in older children/adults Secondary (cross- Reactivity inhalant allergens) Raw apple (and botanicaly related fruit-rosacea Hazelnut, raw vegs. Primary (persistant): Peanuts Tree nuts Seeds Shellfish/ Sea food
Food triggers Older children/adults Lactose One or more Fodmaps Milk/dairy Wheat/gluten Sometimes Sulphites Histamine/ biogenic amines
Compliance is not an issue Allergy-focused diet history Explain symptoms, risk level, prognosis Take the lead Explain what is evidencebased and what is not Plan for diagnosis and treatment in collaboration with peadiatric allergist
Misperceptions by parents Non-evidence based approaches
Frequently asked questions by parents Top 2 Vlieg & Melse Dietitians UK: Mackenzie et al. Symptom reduction by diet for my child Nutritious diet, no deficiencies. Safe diet, prevention of allergic reactions Nutritious diet, no deficiencies. As normal life as possible for my child? Emotional support Mackenzie et al. Ann Allergy Asthma Immunol 2015;114:23-29
Frequently asked questions by parents USA, Dietitian s practice L. Kronisch Texas, abstract AAAAI 2018 Nutritious diet, no deficiencies How to deal with May contain labelling Introduction of new foods into the diet Sequence of introduction of weaning foods Which supplements, which hypoallergenic formulas
Infant with suspected CMA. What do parents need from dietitian counseling? Dietetic expertise in CMA. Avoidance diet during breast feeding or Appropriate choice of hypoallergenic formula How to wean: when to start, how to introduce, how to deal with common food allergens, such as peanut and egg. Nutritious diet to support optimal growth, development of oral motor skills How strict avoid: 100%, use of small amounts, use of baked milk or baked egg? Emotional support
Allergy-focussed diet history To answer these questions, to link symptoms to food, and for optimal dietary management: take an allergy-focussed diet history
ALLERGY FOCUSSED DIET HISTORY TOOL Educational tool for use in non-specialist secondary/ tertiary centers To be used by dietitians, consultants, nurses, general practitioners and junior medical staff
EAACI Task Force set up in 2012 Complementary to the EAACI Food Allergy guidelines Developed paediatric and adult tools based on expert opinion Published February 2015
Symptom Type, speed of onset and reproducibility History: medical, family, atopic Slide by Isabel Skypala Co-factors History Food triggers, plus quantity eliciting reactions Dietary adequacy & nutritional issues Foods eaten and avoided
The allergy focussed diet history Main purposes: Identify suspected foods: link symptoms to food: IgE mediated, non-ige med. or different Assess allergic status and risk: referral to allergist or allergy specialist centre? Assess nutritional risk: referral to dietitian? Draft plan for further testing Draft plan for dietary management
Symptoms and atopic history Example of form *Requires onward referral for specialist allergy assessment
Allergy focussed diet history Interpretation of History - Symptoms Example of form
Red flags in diet history in children for onwards referral Poor growth Multiple food eliminations Severe allergic disease Selective eating behavior Deficient or imbalanced diet
Five red flags /warning signals for inadequate or imbalanced diet 1. Poor growth 2. Multiple food eliminations/ Long standing eliminations 3. Disease severity 4. Selective eating behavior, impaired oral motor skills 5. Nutritionally deficient or imbalanced diet
Proactive dietary management Avoidance diet when breast feeding Select appropriate hypoallergenic formula in CMA Early introduction of peanut/egg Traces/baked milk/egg Immune enhancing diet
Hypoallergenic formulas for treatment of cow s milk allergy (Brands are country specific) Extensively hydrolysed formula (ehf) Amino acid based formula Whey hydrolysate NO Caseïnehydrolysate for hypoallergenic formula treatment Wei/Caseïnehydrolysate First choice Severe cases (IgE med. and non- IgE med.), EoE, Insufficient effect of ehf
Hypoallergenic formulas Allergenicity Degree of hydrolysation Type of formula Indication Potentially allergenic Nonallergenic Cow s milk formula Hypoallergenic: Partially hydrolysed (phf) Extensively hydrolysed (ehf), based on whey Or casein Amino-Acid based formulas - Prevention? Treatment Treatment
Dietary management Key treatment of food allergy = AVOIDANCE DIET in breastfed and bottle fed infants Dietary management -Aims: Reduce symptoms Choose the appropriate hypo-allergenic formula Prevent reactions to foods Prevent unnecessary avoidance Ensure normal This growth was 2012 and development Provide a healthy diet with sufficient nutrients Provide alternatives for a normal live Venter C, Laitinen K, Vlieg-Boerstra B. J Allergy (Cairo). 2012;2012:269376.
Pro-active approach in 2018 Past Avoid common allergenic foods for the prevention of food allergy In case of food allergy: avoid as strict as possible Wait and see until tolerance has developed Today Early introduction of common allergenic foods to prevent the development of food allergy In case of food allergy, try to introduce traces and baked milk or baked egg (less allergenic, in baked goods) Pro-active testing (e.g. nuts) Healthy, immune enhancing diet, through microbiome and nutrient dense foods
Leap study
Leap study results
Published guidelines for prevention of peanut and egg allergy - USA 4 recipe options with dosing scedule
Option 1. Smooth peanut butter puree recipe (3.96 g peanut protein) Togias et al. J Allergy Clin Immunol. 2017 Jan;139(1):29-44. Bird JA et al. J Allergy Clin Immunol Pract. 2017;5:301-311.e1.
Dutch protocol - Early introduction Peanut Mix peanut butter with baby food puree 10 40 100 300 850 1700 mg protein 0,5 1,5 4 g 8 g peanut butter
Dutch protocol - Early introduction Hen s egg Mix stir fried egg with baby food puree 13 mg 40 mg 130 mg 390 mg 850 mg 1700 mg eiwit 1/600 egg 1/150 egg 1/50 egg 1/15 egg 1/7 egg 1/3 gg
2017 Stronger need to develop effective prevention & treatment strategies! PanEuropeanNetworks. Health, Issue 02, Augus 2017. www.paneuropeannetworks.com Treatment of food allergy = Elimination + prevention of deficiencies + immune enhancing diet Reduce inflammation and improve barrier function in the gastro-intestinal tract + enhance immune system / gastro-intestinal microbiome
THANK YOU b.vlieg-boerstra@olvg.nl