Nutritional Considerations in Food Allergy Patients

Liz Hudson MPH, RD 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) 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) Overview

Source: FARE www.foodallergy.org 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 FALCPA

Major Ingredients not Products that must Products not Allergens covered by FALCPA comply with FALCPA covered by FALCPA Milk Gluten containing grains Food products Raw agricultural aside from wheat commodities such as meats, fruits, and vegetables Egg Mollusks (clams, oyster, Dietary supplements Alcohol, spirits scallop) 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. 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. 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. 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 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self- perceived 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):1150–5. Epub 1994/11/01. [PubMed: 7921115] 8. -Rona, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: a meta- analysis. The Journal of allergy and clinical immunology. 2007; 120(3):638–46. Epub 2007/07/14. [PubMed: 17628647] 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 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):1648–51. 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):518–21. 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):605–12. 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. 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? 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. 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. 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 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 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 Nutrition Comparison of Milk Alternatives

Nutrient Cow’s Soy Milk Soy Milk Almond Almond Almond Rice Rice Milk Coconut Oat Hemp Pea Profile Milk (Original) (vanilla) Milk Milk Milk Milk (vanilla) Milk Milk Milk protein (vanilla) (chocolate) based Milk (Ripple®)

Calories 150 110 100 60 80 120 120 130 80 130 70 100 per 8 oz Protein 8 8 6 1 1 1 1 1 0 4 3 8 (grams) per 8 oz Fat 8 4.5 3.5 2.5 2.5 3 2.5 2.5 5 2.5 5 5 (grams) per 8 oz Calcium 300 450 450 450 450 450 300 300 450 350 300 450 (mg) per 8 oz Vitamin ~100- 120 120 100 100 100 100 100 100 120 120 120 D (IU) per 125 8 oz 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 Infant Formulas for cow’s milk allergy or milk/soy FPIES

Food Allergy Symptoms First Choice Formula Second Choice Formula Recommendation Recommendation Low risk of anaphylaxis Extensively hydrolyzed casein May consider soy after 6 (Alimentum or Nutramigen) months Amino acid based (Elecare or Neocate) High risk of anaphylaxis Amino acid based (Elecare or Extensively hydrolyzed casein Neocate) (Alimentum or Nutramigen) Allergic proctocolitis or Food Extensively hydrolyzed casein Amino acid based (Elecare or protein-induced enterocolitis (Alimentum or Nutramigen)* Neocate) syndrome (FPIES) Eosinophilic esophagitis 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, 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 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 Nutrient dense alternative grains for wheat allergy • Almond meal • Oat • Arrowroot • Potato starch • Barley • Quinoa • Buckwheat • Rice • Chickpea flour • Rye • Corn • Sorghum • Fava bean flour • Soy flour • Flaxseed meal • Tapioca • Millet • Teff 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. 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) Risk, Testing Modalities, and Treatments

Henry, M. Nutrition Guidelines for treatment of children with eosinophilic esophagitis. Practical Gastroenterology. June 2014. Non-IgE Mediated Food Allergic Disorders • In general, affect skin and/or gastrointestinal tract and are delayed in onset 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 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 Pathogenesis

• Not well understood Acute vs. Chronic FPIES

Source: Mane, SK. Bahna SL. Clinical manifestations of food protein-induced enterocolitis syndrome. Curr Opin Allergy Clin Immunol. 2014 Jun; 14(3): 217–221. 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 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. J Allergy Clin Immunol 2011: 127: 647-53 Mehr S et al. Pediatrics 2009; 123: e459-64 Nowak Wegrzyn A et al. Pediatrics 2003; 111: 829-835 Sopo S et al. Clin Exp Allergy 2012; 42: 1257-65. Ruffner et al. J Allergy Clin Immunol: In Practice; 2013; 1: 343-9 Infant Formulas for cow’s milk allergy or milk/soy FPIES

Food Allergy Symptoms First Choice Formula Second Choice Formula Recommendation Recommendation Low risk of anaphylaxis Extensively hydrolyzed casein Amino acid based (Elecare or (Alimentum or Nutramigen) Neocate) High risk of anaphylaxis Amino acid based (Elecare or Extensively hydrolyzed casein Neocate) (Alimentum or Nutramigen) Allergic proctocolitis or Food Extensively hydrolyzed casein Amino acid based (Elecare or protein-induced enterocolitis (Alimentum or Nutramigen)* Neocate) syndrome (FPIES) Eosinophilic esophagitis 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 exclusively and partially breastfed infants receive 1 mg iron per kg per day starting at 4 months of age until iron- containing complementary foods have been introduced to account for infants born with low iron stores

Source: American Academy of Pediatrics 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. 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 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 Food Introduction: What can they eat? • Usually start with age appropriate fruits, vegetables, and meats. • Single-ingredient foods should be introduced one-at-a- time, 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 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 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! • http://www.med.umich.edu/i/pteducation/do cs/Allergy/FPIEShandout.pdf 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 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. Pathophysiology

• Allergic mechanism is poorly understood • Likely both IgE-mediated and non-IgE mediated processes involved • Environmental allergies are also a potential component Eosinophilic Esophagitis

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

• Steroid therapy: swallowed budesonide • Acid suppression • Dietary management Dietary Management: 3 approaches

• Elemental dietary therapy

• Targeted dietary elimination

• Empiric dietary elimination 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 Targeted Dietary Elimination

• Most common approach in our clinic • Specific foods are avoided on the basis of food allergy testing • Milk • Beef • Egg • Chicken • Soy • Rice • Wheat • Potato • Peanut • Pork • Corn 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 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 Nutrition Risks Associated with EoE

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