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Question #1

A 7-year-old boy with A. Intravenous fat an enterocutaneous emulsion fistula develops an B. Amino acid urticarial rash the day solution that he is started on C. Pediatric parenteral nutrition. Multivitamin All of the following solution constituents of his parenteral nutrition D. Dextrose could cause the rash EXCEPT: Question #2:

An 18-month-old vegetarian A. Fat girl with presumed milk and B. Vitamin D soy protein allergy is drinking 32 ounces of enriched C. Energy almond milk per day. She D. Zinc also eats rice, wheat, corn, fruits, and vegetables but does not consume any egg or meat products. She does not receive any vitamin or mineral supplementation. You are concerned about her intake of all of the following EXCEPT: Question #3:

A 6-year-old Asian boy is seen A. Assessment of growth and by a dietitian for follow-up nutrient intake nutritional assessment and B. Suggesting an age- education. His parents report appropriate beverage he is allergic to milk, soy, and C. Recommending follow-up peanuts. He has a history of with allergist as patient is anaphylaxis while eating tolerating milk and soy peanut butter a year ago. His D. Suggesting food current intake includes tofu stir- challenge of peanut fry and milk chocolate candy butter at home bars. Parents report he eats these foods at least once a week without any problems. He does not drink a milk substitute. All of the following must be done or considered at this visit EXCEPT: Question #4

A 6-month-old breastfed A. This consistent with IgE- infant has significant mediated anaphylaxis. vomiting and diarrhea B. This is most likely food within hours of being given protein-induced a bottle of cow’s milk enterocolitis syndrome formula. His mother reports that this has happened C. Cow’s milk protein must each time he has been fed be eliminated from the the formula. She denies any child’s diet skin rashes. A serum lab for D. In addition to IgE directed against cow’s breastfeeding, a protein milk protein is negative. All hydrolysate formula of the following are true may be appropriate about this child EXCEPT: Learning Objectives

• Improve understanding of nutrition management of children with multiple food allergies • Describe the nutrition assessment of children with food allergies • Understand the food and non-food issues that may impact the provision of nutrition support in children with food allergy Food Allergy – Concern?

• Increased public health concern in Western World • Greater problem in children than in adults • Associated with poorer nutrition outcomes What’s the story?

• “Telling Food Allergies From False Alarms” (The New York Times) • “Is Your Kid Truly Allergic? Tests Add to Food Confusion” (The Wall Street Journal) • “Adverse Reactions to Food: Allergies & Intolerance” (Digestive Diseases) • “’Allergic Girl’ teaches how to eat out with allergies” (CNN.com) • “This allergies hysteria is just nuts” (British Medical Journal) • “Children at risk in food roulette” (ChicagoTribune.com) • “Fear and Allergies in the Lunchroom” (Newsweek) • “Food Allergen’s Attack” (Food Service Director) • “Food Allergies Take a Toll on Families and Finances” (The New York Times)

Food Allergens

Identified as a protein or glycoprotein

Food Allergy May be more or less common Resist depending on denaturation the society or by heat or acid ethnicity What is Food Allergy? • Two important points: – An immune response • Reproducible response to food protein. • Positive skin prick test or high blood test (serum specific IgE level) to the food can not diagnose food allergy without a reaction or previous exposure to food – Different from a food intolerance • Example: Lactose intolerance – GI symptoms from milk sugar (not protein) – Not an immune response – Often can tolerate some milk in some forms or different amounts (such as yogurt or cheese) • Other intolerances can include; reactions to preservatives (MSG), alcohol, caffeine, theobromine in chocolate. Defining Food Allergy (Immunologic Reaction to Food)

IgE Mediated Syndromes Mixed IgE and Non-IgE Non-IgE Mediated Mediated Syndromes Syndromes Oral allergy syndrome Eosinophilic Esophagitis Protein-induced enterocolitis Anaphylaxis Eosinophilic gastritis Protein-induced enteropathy Urticaria Eosinophilic gastroenteritis Food protein-induced enterocolitis syndrome Angioedema Atopic dermatitis Dermatitis herpetiformis, celiac diease Food Allergy

• 15 million Americans have food allergies • 3 million are school aged • Between 1997 & 2007 prevalence of childhood food allergy increased by 18% • 150 reported deaths each year from anaphylaxis related to food allergies in the United States

2008 National Center for Health Statistics assessment The Food Allergy & Anaphylaxis Network; Food Allergy Facts and Statistics for the U.S. 2012 Food Allergies in the United States

• Prevalence of food allergy in general population is 1-2% • Nearly 3 million children have food allergies – 8% of all children – Young children affected most • Food allergies may be resolving more slowly than previous decades – Many children still allergic beyond age 5 years – Some persist throughout life Major Food Allergens

• Egg • Milk • Peanut • Tree nut • Fish • Shellfish • Soy • Wheat Table of Cross Reactive Foods

Sicherer SH: J Allergy Clin Immunol, 2001 Evaluation of Suspected Food Reactions ALLERGY TESTING How are Food Allergies Diagnosed? • History of reactions at home – Allergy testing must match history of reactions – 50-90% of supposed food allergies are not accurate • Blood tests – Specific Serum IgE testing (sIgE) • Skin tests – Scratch tests

Diagnosis

• Do not test for foods a child has not been exposed to – For example, do not test strawberry, beef or broccoli for a 6 month old that has never eaten these foods and is not breastfed • Do not test for foods the patient tolerates

Test Results – What do they mean? • Skin tests and serum specific IgE tests can both give false positive results – About 50% • Example – Positive serum specific IgE test for milk – The child drinks milk with every meal – What do these test results mean? • Broad screening should NOT be done without history of reaction because of the high rate of false positives Skin Prick Testing

Photos with patient permission

Test Results

• Negative skin test or serum specific IgE means the IgE antibody is not present (>95% specific) • Positive skin test or specific IgE – Indicates that the IgE antibody is present – Does NOT necessarily mean that patient will have a reaction – 90% sensitive – 50% specific – Larger skin test size/higher IgE level correlates with likelihood of reaction but does not tell you how severe the reaction will be Did I eat something while I was pregnant that caused my child’s allergy? I craved peanuts when I was pregnant…

PREVENTION Prevention of Food Allergies

• Avoiding foods in pregnancy does not seem to prevent allergy, eczema, or asthma • Avoiding or delaying foods in infancy does not prevent allergy for infants who are not high risk

American Academy of Pediatrics Clinical Report January 2008; www.aap.org Prevention of Food Allergies

• High-risk children - parent or siblings with food allergy – Breast milk or hyrdolyzed infant formula until 4 months of age – Soy formula likely doesn’t prevent allergies – Delay introduction of solids until 4—6 months of age • No reason to delay introduction past this time • Okay to include foods that are considered to be highly allergic such as fish, eggs and foods containing peanut protein.

American Academy of Pediatrics Clinical Report January 2008; www.aap.org Natural History of Food Allergy • Most children with food allergies will eventually tolerate milk, egg, soy and wheat • The age that most children outgrow the allergy varies by food • If initial serum specific IgE (sIgE) level for a food is high, they are less likely to outgrow the allergy

Hourihane, 1998; Sampson, 2004; Boyce, 2010; Wasserman, 2011 Food Challenge

• Performed to determine tolerance • Conducted in an allergist’s office where emergency equipment is available • Skin prick test and serum specific IgE test results meet criteria to qualify for a challenge • Patient is fed the food in increasing amounts watching for a reaction

Fatalities in Anaphylaxis

• Food anaphylaxis is the leading cause of anaphylaxis treated in emergency department – 30,000 cases per year – 150—200 deaths per year • Peanut, tree nut and seafood account for most of these reactions • Cannot be predicted by past reactions

Sampson et. al. Pediatrics 2003 111:1601-8 Fatal Food-Induced Anaphylaxis • 32 cases of fatal anaphylaxis reviewed • Most were teens or young adults • Peanuts and tree nuts caused >90% of reactions • 2/3 of the patients had asthma • Most did not have epinephrine available or did not use it

Bock SA, et al. Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol 2001;107:191–193 Key Point: Benadryl will NOT block anaphylaxis • A history of a mild reaction does not mean that future reactions will be mild • Consider an Epi Pen for all at risk of anaphylaxis • It is never wrong to use the Epi Pen • When you are considering using the Epi Pen….. use it!

Sampson, H., et. al., 2007 MANAGEMENT Management It Takes A TEAM • No cure for food allergies • Strict avoidance • May lead to nutrition consequence • Careful diagnosis of non-IgE mediated allergy • Future treatment – Anti-IgE monoclonal antibody – Allergen immunotherapy • 3 forms under investigation: oral, sublingual and epicutaneous Other Related Diagnosis

• Cow’s Milk-Protein Allergy (CMP) • Eosinophilic Esophagitis • Food Protein-Induced Enterocolitis Syndrome (FPIES) Management It Takes A TEAM • Accurate diagnosis of food allergens • Assessment of nutrition status • Institution of elimination diet • Prevention of adverse reactions • Proper emergency action plan • Treatment of associated atopic disorders Management It Takes A Team • Ongoing care by dietitian – Monitoring of nutrition status and growth – Education • Ongoing care by allergist – Monitoring for development of tolerance • Ongoing care by gastroenterologist – Monitoring for remission of symptoms

NUTRITION & GROWTH ASSESSMENT Nutrition Assessment

• Growth • Intake/Feeding History – Primary nutrition concern – Distribution of fat, protein for all children: and carbohydrate • Poor growth Vitamin and mineral intake – History of weight gain & – growth – Barriers to meeting intake – Current weight gain & needs growth • Current Intake – Assessment of body – Collection: 24 hour recall composition or 3day food record – Type & volume of food & liquid – Formula or breast milk, vitamin supplementation, or other supplementation

Key Nutrients

• Carbohydrates • Protein • Fat • Fiber • Water • Vitamins and Minerals – Calcium – Iron – Vitamin D Distribution of Calories

Fat Fat Protein Protein Carbohydrate Carbohydrate

Appropriate distribution of calories Inappropriate distribution Example: Toddler with age of calories appropriate beverage & Example: Toddler drinking rice variety of solids milk & eating few foods Health Risks of Poor Nutrition

Deficient Nutrient Health Risk Calories Malnutrition, underweight, obesity Protein Low muscle mass Poor immune function Fat Essential fatty acid deficiency Iron Anemia Poor endurance Calcium & Vitamin D Rickets Osteomalacia Zinc, Vitamins A, C, & E Poor wound healing Zinc Altered taste Poor appetite Vitamin K Poor blood clotting Clinical Signs of Nutrition Status • Height/weight • Fluid status • Fat stores • Muscle mass • Skin, nails, hair, teeth, lips, gums • Energy level Serum Measures of Nutrition Status • Iron stores – Hemoglobin, hematocrit, ferritin, iron, TIBC • Immune status – Total lymphocyte count • Stores of specific vitamins and minerals – Zinc, folate, vitamin D, etc. • Nutrition labs should be drawn if: – Clinical signs of poor nutrition – Avoiding one or more food groups – Poor protein intake – Recommended by dietitian

Diet History

• 24 hour recall • 3 day food record • Formula use • Supplement use • Food habits • Household food restrictions • Recent diet changes Nutrient Intake Standards

• Based on the Dietary Reference Intakes (DRIs) – Recommendations for calories, fat, protein, vitamins, minerals, and trace elements – Based on current research – Reflect the benefits of adequate nutrition (not just prevention of deficiency) – Most recent update – January 2011 • Increased calcium and vitamin D requirements – Complete DRI tables available online • http://www.iom.edu/Activities/Nutrition/SummaryD RIs/~/media/Files/Activity%20Files/Nutrition/DRIs/5_ Summary%20Table%20Tables%201-4.pdf Growth Assessment

• Growth charts – 0-24 months = WHO growth chart – 2-20 years = CDC growth chart – Weight – Length or Height – Weight for length or BMI for age – Head circumference (under age 2) • % ideal body weight • Growth velocity • Z-scores

Growth Velocity

Comparison of growth for two girls with the same weight and length at 10.5 months

● Normal growth rate  Deceleration in growth rate NUTRITION AND FOOD ALLERGIES Impact of Food Allergies

Restricting major food groups means missing important nutrients

49 Nutrition Risk

• At least 25% will have micronutrient deficiencies • Risk increases with additional problems – Picky eating – Feeding difficulties – Social concerns – Poor growth – Financial concerns

Nutrition Risk

• Important to identify “Red Flags” – Growth concerns – More than 1 food allergy • Or avoiding complete food group such as “milk” – Concerns with feeding history – Clinical signs of deficiency on physical exam – Altered nutrition related labs Food Elimination Diet… The Bottom Line • How many foods are they avoiding? • Is it feasible to meet nutrient goals? • Where is supplementation needed? – Special formula – Vitamin and/or mineral supplementation – Oil supplementation Key Micronutrients Provided by Food Allergens

Allergen Micronutrients Provided Alternative Food Substitutes

Milk vitamin A, vitamin B1, vitamin B2 (riboflavin), meats, legumes, whole grains, nuts, vitamin B12, vitamin D, vitamin B5 (pantothenic mushrooms, fortified foods/beverages acid), calcium, magnesium, selinium, zinc, (fortified with B vitamins, calcium, and potassium, phosphorus vitamin D), fish, bright yellow and orange vegetables

Soy thiamin, vitamin B2 (riboflavin), pyridoxine, folic meats, legumes, enriched whole grain acid, calcium, phosphorus, magnesium, iron, bread products, egg, nuts, peas, seeds, zinc milk, dried fruit

Wheat thiamin, vitamin B2 (riboflavin), niacin, iron, alternative fortified grains (barley, rice, oat, zinc, selenium, chromium, folic acid if fortified corn, rye, quinoa, amaranth, farina), soybean, legumes, egg, milk, nuts, seeds, apples, banana, spinach and potatoes

Egg vitamin B12, vitamin B2 (riboflavin), vitamin B5 meats, legumes, beans, lentils, whole (pantothenic acid), biotin, selenium, iron, folic grains, nuts, leafy green vegetables, fish, acid, vitamin E, chromium dried fruit Key Micronutrients Provided by Food Allergens

Allergen Micronutrients Provided Alternative Food Substitutes

Peanuts/ vitamin E, biotin, copper, folic acid, niacin, whole grains, vegetable oils, soybean, egg, Tree nuts magnesium, manganese, chromium other legumes

Fish/ vitamin B6, vitamin E, niacin, phosphorus, fortified whole grains, meats, oils, Shellfish selenium, omega-3 fatty acids, folic acid, copper, soybean, seeds, nuts, milk, egg zinc, potassium, vitamin A NUTRITION INTERVENTION Intervention

• Identification of nutrition problems – Identification of other potential referrals • Establish nutrition goals • Provide targeted nutrition interventions • Evaluate outcomes/reassess nutrition • Revise nutrition plan • Establish ongoing monitoring • Nutrition education

Impact of the Allergy Restricted Diet • Grocery Shopping • Cooking • Socializing • Travel/Vacations • Eating Out • Family Relationships • Lotions, Pet foods etc.

Education

• Education is the cornerstone for compliance and a nutritionally adequate diet • How to read food labels (every time!!) • Forms of food/ingredients to avoid • Foods/ingredients to include • Substitutions/alternatives for nutrient goals • Meal and snack planning • Cross-contact • Tips for dining out • Recipes • Resources and Support Groups Food Allergen Labeling & Consumer Protection Act • Effective January 1, 2006 • Identify 8 major food allergens – Milk, Egg, Peanut, Tree Nut, Fish, Shellfish, Wheat and Soy • Identify presence in spices, flavorings, etc. • Precautionary labeling – “May contain” or “Processed on” – is voluntary Food Allergen Labeling & Consumer Protection Act

• Gluten Free – “Gluten free” regulated starting August 2014 • Must contain less than 20 parts per million of gluten • May still contain a small amount of wheat • Patients must read ingredient list – Gluten free labeling is optional Common Sources of Hidden Food Allergens Egg Milk Nuts Soy Wheat Rice Pasta Bread Cereals Bread/ Cereal Baby Food Waffles Bread Cereals Egg Rolls Muffins/ Gluten Free Bread Cake Products Egg Beaters Candy/ Cakes/ Crackers Soy Sauce Cake Chocolate Cookies Candy Frozen Frozen Low Fat Beef Low Fat Beef Muffin Mixes Desserts Desserts Franks Franks Marsh- Canned Tuna Nut Butters Chicken Hot Chicken Hot Waffles mallows Dogs Dogs Waffles Processed Sauces/ Chili Bouillon Modified Soup Meats Cubes Food Starch Milk Substitutes/Beverages • Whole milk is a good source of: – Calories – Fat – Protein – Calcium – Vitamin D • Especially for 1 year olds – Need fat for brain development – Calories for growth – Texture of meat may be difficult to eat Milk Substitutes/Beverages

Whole Nutrients per 8 oz. Milk Soy Milk Almond Milk Rice Milk

Calories 150 80 to 130 60 to 70 120 Protein (g) 8 7 to 11 1 to 5* 1* Carbohydrate (g) 11 7 to 13 7 to 8 23 Fat (g) 8 2.5 to 4.5 2 to 4 2.5 Saturated fat (g) 5 0 to 0.5 0 0 Calcium (mg) 294 200 to 450 100 to 450 300 Vit D (IU) 100 40 to 140 100 to 120 100 Milk Substitutes/Beverages

Almond Coconut, Whole Coconut Almond, & Chia Nutrients per 8 oz. Milk Hemp Milk Blend Blend

Calories 150 70 50 70 Protein (g) 8 2 to 3* <1* <1* Carbohydrate (g) 11 1 5 8 Fat (g) 8 5 to 6 3 4 Saturated fat (g) 5 0.5 1 2.5 Calcium (mg) 294 300 450 300 Vit D (IU) 100 100 to 120 100 100 Milk Substitutes/Beverages • Key takeaways – If allergic to milk… • Choose soy milk • Add fats to food – If allergic to milk and soy… • 1 year old – Elecare Jr, Neocate Jr, EO28 Splash – May continue infant formula or breast milk – Consult the dietitian • 2 years old and eating meat – may try other milk substitutes – With any substitutes, must read the label for calcium and vitamin D content Nutritionally Complete Formulas • Standard – Milk based – Enfamil Infant, Similac Infant (19 calories/ounce), Pediasure • Soy – Soy based – Enfamil Prosbee, Good Start Soy, Bright Beginnings Soy Drink • Partially hydrolyzed – Proteins are partially broken down – NOT hypoallergenic – Good Start Gentle, Enfamil Gentlease Nutritionally Complete Formulas • Extensively hydrolyzed – Proteins are extensively broken down, but still peptides – Considered to be hypoallergenic – Similac Alimentum, Enfamil Nutramigen, Pediasure Peptide • Elemental – Single amino acids – Neocate Infant, Elecare Infant, Neocate Jr, Elecare Jr, EO28 Splash

Micronutrient Supplementation • Must be chewable, not gummy • Must contain iron • Age appropriate serving

• Complete Chewable Multivitamin with Iron (many brands) • Nature’s Plus Animal Parade Gold Children’s Liquid • Nature’s Plus Animal Parade Sugar Free Children’s Multivitamin • Vitaflo FruitiVits Powder Multivitamin • Nano VM Powder • Nature’s Plus Source of Life Power Teen

Guidelines for Baked Allergens • Must be baked to a high temperature – Structure change – Cooked thoroughly – Home made should be baked in individual serving size • Muffin, cupcake (not bread or cake) • Commercial bread is okay • Must be mixed into the product – Milk allergy – use milk free chocolate chips • Allergen must be a small amount – Not in the first 3 ingredients for commercial products – 20 ml milk or less per serving (challenge) – ¼ egg or less per serving (challenge)

Groetch, M. & Nowak-Wegrzyn, A. Practical approach to nutrition and dietary intervention in pediatric food allergy. Pediatric Allergy & Immunology, 2013, 24:212-221 Nowak-Wegrzyn, A. & Fiocchi, A. Rare, medium, or well done? The effect of heating and food matrix on food protein allergenicity. Current Opinion in Allergy and Clinical Immunology, 2009, 9:234-237.

APPLICATION SAMPLE MENU: 1 TO 3 YEAR OLD CHILD (DIET 1) DIET 1 ANALYSIS

Nutrient % Goal

Calories 1490 >100%

Protein 47 grams 360%

Fat 55 grams 33% total calories

Calcium 1100 milligrams 157%

Vitamin D 203 IU 34%

Iron 9.9 milligrams 141%

Zinc 8.9 milligrams 297% SAMPLE MENU: 1 TO 3 YEAR OLD CHILD WITH MILK, EGG AND PEANUT ALLERGY (DIET 2)

Problem Nutrients: •Calories • Protein • Fat • Calcium • Vitamin D • Iron Diet 2 Analysis

Nutrient % Goal

Calories 305 25%

Protein 5 grams 41%

Fat 2 grams 6% total calories

Calcium 98 milligrams 14%

Vitamin D 20 IU 3%

Iron 4 milligrams 59%

Zinc 2.6 milligrams 87% REVISED MENU: 1 TO 3 YEAR OLD CHILD WITH MILK, EGG AND PEANUT ALLERGY (DIET 3) DIET 3 ANALYSIS

Nutrient % Goal

Calories 1360 >100%

Protein 42 grams 321%

Fat 49 grams 32% total calories

Calcium 754 milligrams 108%

Vitamin D 285 IU 48%

Iron 10 milligrams 147%

Zinc 6 milligrams 201% Finding allergen free foods

Keep it Simple: Single ingredient foods

Intranet: Recipes, Online recipes and grocery stores more recipes Learn to Read the Food Label

Regular and Food Specialty Manufactures Grocery Websites Stores ENTERAL NUTRITION Enteral Nutrition

• Straight forward • If child with Cow’s milk protein • If child with other protein allergies • Formula intolerance – Often secondary to food allergies – Transition to protein hydrolysate/elemental formula – Often diagnosed retrospectively PARENTERAL NUTRITION Parenteral Nutrition

• Minimal data • Egg Allergy • Soy Allergy Parenteral Nutrition-Case Reports • Variety of allergies to PN • More common in children • Manifestations – Skin rashes (most common) – Dyspnea, cyanosis, nausea, vomiting, headache, flushing, fever, chest pain • Can occur – First administration – After several days – After reinstitution following hiatus Parenteral Nutrition-Case Reports • Attributed to: – IV fat emulsions – Crystalline amino acid solutions – Multivitamin mixtures – Latex stopper on the IV fat emulsion Parenteral Nutrition- Management • If reactions occur, – PN should be stopped – Appropriate drug treatment for reaction • If severe and requires ongoing PN – Multidisciplinary approach – Allergist, pharmacist, nutrition-support physician, dietitian – Two approaches when mild: • SPT of PN components and removal of offending agent • Identify offending agent through trial and error – When severe: • IV desensitization in the ICU has been described • Unclear if this method actually worked

Parenteral Nutrition- Management • IV Iron • Cause significant allergic reactions • Iron dextran, sodium ferric gluconate complex in sucrose and iron sucrose • Lowest risk – iron sucrose • Least expensive – iron dextran • Test doses Question #1

A 7-year-old boy with A. Intravenous fat an enterocutaneous emulsion fistula develops an B. Amino acid urticarial rash the day solution that he is started on C. Pediatric parenteral nutrition. Multivitamin All of the following solution constituents of his D. Dextrose parenteral nutrition could cause the rash EXCEPT: Question #2

An 18-month-old vegetarian A. Fat girl with presumed milk and soy protein allergy is drinking B. Vitamin D 32 ounces of enriched almond milk per day. She C. Energy also eats rice, wheat, corn, fruits, and vegetables but D. Zinc does not consume any egg or meat products. She does not receive any vitamin or mineral supplementation. You are concerned about her intake of all of the following EXCEPT: Question #3

A 6-year-old Asian boy is seen A. Assessment of growth and by a dietitian for follow-up nutrient intake nutritional assessment and B. Suggesting an age- education. His parents report appropriate beverage he is allergic to milk, soy, and peanuts. He has a history of C. Recommending follow-up anaphylaxis while eating with allergist as patient is peanut butter a year ago. His tolerating milk and soy current intake includes tofu stir- D. Suggesting food fry and milk chocolate candy challenge of peanut bars. Parents report he eats butter at home these foods at least once a week without any problems. He does not drink a milk substitute. All of the following must be done or considered at this visit EXCEPT: Question #4

A 6-month-old breastfed A. This consistent with IgE- infant has significant mediated anaphylaxis. vomiting and diarrhea B. This is most likely food within hours of being given protein-induced a bottle of cow’s milk enterocolitis syndrome formula. His mother reports that this has happened C. Cow’s milk protein must each time he has been fed be eliminated from the the formula. She denies any child’s diet skin rashes. A serum lab for D. In addition to IgE directed against cow’s breastfeeding, a protein milk protein is negative. All hydrolysate formula of the following are true may be appropriate about this child EXCEPT: FOOD ALLERGY RESOURCES FOOD ALLERGY RESOURCES

• FARE – www.foodallergy.org – 1-800-929-4040 • School Food Allergy Program—free to schools in the USA • Resources for dining out, including a restaurant training program – http://www.foodallergy.org/managing- food-allergies/dining-out • FAAN Anaphylaxis video • National Annual Conference FOOD ALLERGY RESOURCES

• Children’s Hospital of Wisconsin – http://chw.org – Search: teaching sheets – Search key words: allergy, asthma, eczema – Medical I.D. – Feeding Your Baby 0-12 months – Feeding Your Toddler 1-3 years – Calcium and Vitamin D in Your Child’s Diet – Increasing Iron in Your Child’s Diet – Increasing Fiber in Your Child’s Diet – Eosinophilic Esophagitis – Food Allergy Overview FOOD ALLERGY RESOURCES

• Academy of Nutrition and Dietetics – Website: http://www.eatright.org • U.S.D.A. Food and Nutrition Information Center – www.nal.usda.gov/fnic/etext/fnic.html • MedicAlert Foundation International – Website: http://www.medicalert.com • ID on me Medic Alert Bracelets – Website: http://www.idonme.com • The American Academy of Pediatrics – Website: http://www.aap.org COMMON BRANDS OF ALLERGEN FREE FOODS "If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health." Hippocrates