Food allergy educational needs of pediatric dietitians: a survey by the Consortium of Food Allergy Research

Precautionary Allergen Labeling: Avoidance for All?

PURPOSE OF REVIEW

Precautionary allergen labeling (PAL) suggests the risk of unintended allergen presence (UAP) in food but is unregulated in most countries and inconsistently applied by food manufacturers. This review evaluates the current use of PAL, its relevance to allergic consumers, and weighs possible advantages and disadvantages of avoiding products with PAL.

RECENT FINDINGS

In most countries, manufacturers are free to decide whether, when, and how to apply PAL resulting in inconsistencies and consumer confusion. Patients with food allergy often interpret PAL incorrectly and without guidance from their health care providers. Health care providers are also prone to misinterpreting PAL, indicating a need for better education. Consumers desire guidance on whether to avoid products with PAL or not. Until further regulatory guidance is available, shared decision-making between patient and provider is required to offer individualized, rather than one-size-fits-all, approaches to PAL.

Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World

Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.

Cow's milk allergy in children impacts parental or caregiver calcium intake

Food allergies have become a global epidemic, affecting more than 10% of the population and 8% of children worldwide. Eliminating or limiting a food group from the diet can adversely impact micronutrient consumption. Milk allergies can impact the amount of calcium consumed in the diet, serving as a barrier to meeting daily calcium needs. Previous research evaluates the nutritional impact food allergies may have on children diagnosed with food allergies; however, there is a marked gap in literature that investigates the impact that children's allergy may have on their parent or caregiver. We hypothesized that milk elimination in a child's diet resulting from a milk allergy is associated with inadequate calcium intake among parents. Study participants (n = 55) lived in the United States and included parents or caregivers of a child with a diagnosed milk allergy (experimental group) and parents of a child without a milk allergy (control group). Calcium intake was estimated by using the validated Calcium Assessment Tool. Results demonstrated that the experimental group consumed significantly less calcium (273 mg/d) than the control group (520 mg/d; P < .01). Notably, both groups consumed inadequate calcium relative to the calcium Recommended Dietary Allowance for adults of 1000 mg/d, although calcium supplementation was not assessed in this study. Key findings from this study indicate widespread inadequate dietary calcium intake and suggest a need for increased calcium consumption in this population.

The Risk of Undeclared Allergens on Food Labels for Pediatric Patients in the European Union

The dietary avoidance of allergens has been widely recognized as the key intervention in the management of food allergies, but the presence of undeclared allergens makes compliance difficult. The aim of this study was to analyze the presence of undeclared allergens in food labeling through RASFF notifications in the European Union, focusing on those allergens that frequently affect the pediatric population and the implicated products, so as to provide useful information for its risk evaluation and the development of educational materials for patients. The results showed milk (20.5%), gluten (14.8%), and nuts (10.9%) to be the pediatric allergens with higher presences. In 80% of the notifications concerning milk and milk derivatives, the specific compound present (lactose or lactoprotein) was not identified. They were mainly present in cereal and bakery products, prepared dishes and snacks, and cacao and confectionery products, all of which are frequently consumed by the pediatric population. The large quantity (7.6%) of undeclared allergens in “free-from-allergen” products was also remarkable, especially in regard to the supposedly not-present allergens. Undeclared allergens in food products pose an evident risk for allergic patients and knowledge of them should take a relevant role in a patient’s nutritional education. It is also necessary to raise awareness among manufacturers and safety authorities.

Managing food allergy and anaphylaxis: A new model for an integrated approach

There is an increasing public concern on food allergy and related anaphylactic reactions that occur mainly at the community level. The perception of the disease is huge among parents who believe that 1 out of 20 children suffers from severe food allergy. The discrepancy between this self-reported prevalence and the real one when a food challenge is performed, points out the gap in the implementation of guidelines for clinical practice. Health professionals as well show scarce adherence to the guidelines both at the Emergency Departments and at the primary care level. Anaphylactic reaction are not recognized, adrenaline is under-used and self-injectable devices are not prescribed. Although education and training are limited to local, spontaneous initiatives from patient's organization and few allergists, the data so far available demonstrate that improvement in knowledge and attitudes can be achieved further to a structured program. There is the need to establish good evidence -based practices for educational intervention that should be adopted in the context of public health policies for food allergy. This would imply a change in legislation in many countries to prevent prosecution for liability of lay people administering adrenaline when properly trained. In parallel an integrated clinical care pathway should be developed by multidisciplinary and multi-professional teams in the context of national Centres of Excellence -CoE. These CoE could drive the progression to digital health create, creating networks of CoE for best practices of care and for clinical trials.

Upskilling healthcare professionals to manage clinical allergy

It has long been recognised that given the high prevalence and considerable impact of allergic disease globally, there needs to be a focus on appropriate training for clinical professionals. The health-economic consequences of allergic disease are significant, with both direct healthcare costs (doctor, nurse and dietitian consultations, hospital admissions and prescribed medications) and indirect costs (lost school and work time, reduced productivity and over-the-counter medications). There is also a well-recognised impairment of quality of life, with less tangible costs including anxiety, distress, discomfort, disability and, occasionally, death. To help to mitigate these effects, there is a need to upskill the professional workforce at all levels, and also to equip those trained with the skills to become future healthare professional trainers. Upskilling the workforce from the grass-roots of undergraduate study in Medical, Nursing and Allied Health Professionals (AHP) through the entirety of training to senior consultant levels could have a major beneficial impact on the patient and their families, lead to a reduction in emergency use of clinical service, and help increase economic productivity.

The Consortium for Food Allergy Research (CoFAR): The first generation

The Consortium for Food Allergy Research (CoFAR) was established by the National Institute of Allergy and Infectious Diseases in 2005 as a collaborative research program bringing together centers focused on the study of food allergy. CoFAR was charged with developing studies to better understand the pathogenesis and natural history of food allergy, as well as potential approaches to the treatment of food allergy. In its first iteration an observational study of infants with milk and egg allergy was established, and studies of oral immunotherapy for egg allergy and sublingual immunotherapy for peanut allergy were initiated, as was a phase 1 study of a recombinant peanut protein vaccine. CoFAR was renewed in 2010 for an additional 5-year period during which the initial observational study was continued, a study of eosinophilic esophagitis was initiated, and new therapeutic trials were established to study epicutaneous immunotherapy for peanut allergy and to compare the safety and efficacy of egg oral immunotherapy to the ingestion of baked egg for the treatment of egg allergy. The results of these efforts will be reviewed in this rostrum, with a brief look to the future of CoFAR.

Promoting and achieving excellence in the delivery of Integrated Allergy Care: the European Academy of Allergy & Clinical Immunology competencies for allied health professionals working in allergy

The multi-disciplinary team approach is an effective model for patient care. Allied health professionals (AHPs) are an important part of such teams, bringing specific knowledge and skills related to the target patient population. The AHPs most often involved in allergy care are nurses and dietitians. Nurses are often involved in the care of patients with all types of allergy and also with asthma, whilst allergy-specialist dietitians provide vital nutritional and dietary support for the diagnosis and management of food allergy. There are many other AHPs who have a role to play in allergy care, including physiotherapists, psychologists, pharmacists and speech therapists, and their involvement is likely to develop as allergy care becomes more rooted in the community. With the development of multi-professional teams comes the requirement for disease-specific knowledge and skill sets, with all allergy team members required to have baseline knowledge and competency of the condition being managed. Whilst some competencies for AHPs practising in other disease states have been published, none are available for allergic disease against which AHPs can be benchmarked. The European Academy of Allergy & Clinical Immunology (EAACI) recognised this need, and supported the establishment of a Task Force to develop allergy-focussed competencies for AHPs. The varied skills, expertise and professional background of the Task Force members enabled the creation of a set of allergy competencies relevant to all AHPs working in allergy. It is recognised that the training and allergy expertise of AHPs, and their role within the allergy setting, will vary considerably depending on the country. However, it is important for patient care, that all AHP involved in allergy services have access to training, of a sufficiently high enough level to be aspirational and enable the continued growth and development of a wide range of allergy services, given the increasing need. The EAACI competencies will provide an important benchmark for allergy knowledge and skills against which education and training can be designed and health care professionals can subsequently be measured. However, more importantly, the EAACI AHP allergy competencies will enable the development and reach of specialist allergy services, with allergy-specialist AHPs undertaking key roles, especially in the community care setting.

Evaluation of an educational programme with workshops for families of children with food allergies

BACKGROUND

When a child is diagnosed with a food allergy, prevention and patient education are the key interventions for maintaining the child's health and quality of life and that of his or her whole family. However, health education activities for the families of children with food allergies are very limited, and most of these activities have not been evaluated. Therefore, the objectives of the present study were to develop an educational programme, to empower its participants through workshops, and to evaluate its results.

METHODS

Several types of educational materials were created specifically for the programme, called "Proyecto CESA" ("STOP-FAR Project: Stop Food-Induced Allergic Reactions"). The programme was carried out in seven Spanish cities and was attended by parents and caregivers. The workshops were led by physicians specialising in allergies and by expert patients. Afterwards, participant learning and satisfaction were evaluated based on questionnaires that were completed both before and after the workshops.

RESULTS

A significant improvement was observed in 29 items out of 40 (McNemar's test). Participant satisfaction with the programme was also very high: 90% rated the course between 8 and 10 points out of a possible 10 (41% rated it as a 10).

CONCLUSION

The face-to-face workshops, which included utilisation of educational materials, had positive results in terms of learning as well as in levels of satisfaction in participating families.

The development and implementation of a training package for dietitians on cow's milk protein allergy in infants and children based on UK RCPCH competencies for food allergies - a pilot study

Background

Many food allergy guidelines have been published worldwide over recent years. The United Kingdom National Institute of Health and Clinical Excellence guidelines and The Royal College of Paediatrics and Child Health food allergy care pathways require dietitians to assist with the diagnosis and management of food allergies, which highlighted the need for further education of dietitians to meet these competencies. The aim of this study was to design a competence based one day education course for dietitians on the diagnosis and management of cow’s milk protein allergy in infants and children.

Methods

A one day training course was developed. Dietitians’ knowledge was assessed via multiple choice questions before and on the day of the course and retention of knowledge was assessed one month after the course. Pre course reading was given once the first assessment was completed.

Results

Thirty seven dietitians attended the course and 32 completed all three assessments. A significant improvement in assessment scores was seen between the pre course and on the day assessments of 7.2% (p < 0.001) and between pre course and post course assessments of 8.9% (p < 0.001). In delegates who rated their perceived level of knowledge as high, a significant increase was seen between pre course and on the day and between pre course and post course (both p < 0.001). Actual increase in knowledge was seen alongside a significant increase in high rating of perceived level of confidence between pre course and on the day and between pre course and post course (both p < 0.001).

Conclusions

Educating dietitians using the format of one day teaching with pre and post course assessment has improved both knowledge and competencies in the diagnosis and management of cow’s milk protein allergy. Further courses in other areas of food allergy could be developed using this approach within the UK and worldwide.

Food allergy competencies of dietitians in the United Kingdom, Australia and United States of America

BACKGROUND

A knowledgeable and competent dietitian is an integral part of the food allergy multidisciplinary team, contributing to effective diagnosis and management of food allergic disorders. Little is currently known about the food allergy training needs and preferences of dietitians. The purpose of this paper is to measure and compare self-reported food allergy competencies of dietitians based in the UK, Australia and USA.

METHODS

A survey of USA-based paediatric dietitians was developed to measure self-reported proficiency and educational needs in the area of food allergy. The survey was modified slightly and circulated online to paediatric and adult dietitians in the UK and Australia. Descriptive statistics and Pearson correlations are presented.

RESULTS

A total of 797 dietitians completed the questionnaire. Competency in "developing food challenge protocols" and "managing feeding problems" were rated the poorest overall across all three settings. A higher level of competency was significantly positively associated with length of practice as a dietitian, percentage of caseload composed of patients with food allergy and training in food allergy. The most popular topics for further training were food additives, pharmacological reactions and oral allergy syndrome.

CONCLUSIONS

There is a need amongst dietitians to increase their knowledge in different aspects of food allergy diagnosis and management, specifically the areas of developing food challenge protocols and management of feeding problems. This study provides valuable information for designing targeted food allergy education for dietitians.

Development and validation of educational materials for food allergy

OBJECTIVE

To develop and validate a food allergy educational program.

STUDY DESIGN

Materials developed through focus groups and parental and expert review were submitted to 60 parents of newly referred children with a prior food allergy diagnosis and an epinephrine autoinjector. The main outcome was correct demonstration of an autoinjector.

RESULTS

The correct number of autoinjector activation steps increased from 3.4 to 5.95 (of 6) after training (P < .001) and was 5.47 at 1 year (P < .05). The mean score for comfort with using the autoinjector (7-point Likert scale) before the curriculum was 4.63 (somewhat comfortable) and increased to 6.23 after the intervention (P < .05) and remained elevated at 1 year (6.03). Knowledge tests (maximum 15) increased from a mean score of 9.2 to 12.4 (P < .001) at the initial visit and remained at 12.7 at 1 year. The annualized rate of allergic reactions fell from 1.77 (historical) the year prior, to 0.42 (P < .001) after the program. On a 7-point Likert scale, all satisfaction categories remained above a favorable mean score of 6: straight-forward, organized, interesting, relevant, and recommend to others.

CONCLUSIONS

This food allergy educational curriculum for parents, now available online at no cost, showed high levels of satisfaction and efficacy.