Practical approach to nutrition and dietary intervention in pediatric food allergy

Elimination diet in food allergy: friend or foe?

OBJECTIVES

To review and discuss the role of an elimination diet in food-allergic children, emphasizing nutritional aspects for a better practical approach.

SOURCES

Non-systematic review of the literature.

FINDINGS

Under an elimination diet, food-allergic patients may suffer from growth impairment or obesity and compromised quality of life. Disease phenotype, age, type, number of foods excluded, comorbidities, eating difficulties, economic status, and food availability must be considered for an appropriate diet prescription. Diet quality encompasses diversity and degree of food processing, which may alter immune regulation.

CONCLUSIONS

A friendly food elimination diet prescription depends on a multidisciplinary approach beyond macro and micronutrients.

Nutritional risks in children with food allergy

BACKGROUND

Food allergies (FA) are a growing problem in the pediatric population and clinical features differ according to the underlying immunological mechanisms. While the primary management strategy is to eliminate the culprit food from the diet, assessment of the potential nutritional risks of elimination is also an integral part of management. In cases that do not improve over time; if you have basic food allergies and multiple food allergies, this can also lead to negative nutritional consequences. The contribution of basic nutrients, economical and easily accessible foods to the diet, is critical and has an important place in meeting the daily adequate intake of many nutrients. In the presence of food allergy, it is necessary to meet the vitamins and minerals that cannot be obtained from allergic foods, with alternative sources or supplements. For example, insufficient calcium intake in cow's milk allergy (CMA), the most common FA in early childhood, is very likely if an alternative supplement has not been introduced. In the management of CMA, choosing the appropriate formula and/or supplement for the clinical characteristics of children, when necessary, has an important place. In conclusion, nutritional risk assessment of children with FA requires a comprehensive, detailed, and multidisciplinary approach.

EAACI Molecular Allergology User's Guide 2.0

Since the discovery of immunoglobulin E (IgE) as a mediator of allergic diseases in 1967, our knowledge about the immunological mechanisms of IgE-mediated allergies has remarkably increased. In addition to understanding the immune response and clinical symptoms, allergy diagnosis and management depend strongly on the precise identification of the elicitors of the IgE-mediated allergic reaction. In the past four decades, innovations in bioscience and technology have facilitated the identification and production of well-defined, highly pure molecules for component-resolved diagnosis (CRD), allowing a personalized diagnosis and management of the allergic disease for individual patients. The first edition of the "EAACI Molecular Allergology User's Guide" (MAUG) in 2016 rapidly became a key reference for clinicians, scientists, and interested readers with a background in allergology, immunology, biology, and medicine. Nevertheless, the field of molecular allergology is moving fast, and after 6 years, a new EAACI Taskforce was established to provide an updated document. The Molecular Allergology User's Guide 2.0 summarizes state-of-the-art information on allergen molecules, their clinical relevance, and their application in diagnostic algorithms for clinical practice. It is designed for both, clinicians and scientists, guiding health care professionals through the overwhelming list of different allergen molecules available for testing. Further, it provides diagnostic algorithms on the clinical relevance of allergenic molecules and gives an overview of their biology, the basic mechanisms of test formats, and the application of tests to measure allergen exposure.

Vitamin D and iron status in children with food allergy

BACKGROUND

Children with food allergy are at specific risk for nutritional deficiencies.

OBJECTIVE

To retrospectively determine prevalence of vitamin D and iron deficiencies in children with or without food allergy (FA).

METHODS

We compared the markers of vitamin D and iron status of 0 to 17-year-olds with cow's milk allergy (CMA) (n = 77), those with other FAs (n = 70), and those with atopy without FA (n = 87) at an academic pediatric allergy practice. Multiple linear regression analyses were performed to determine the impact of CMA and other FAs on vitamin D levels and iron markers.

RESULTS

Vitamin D deficiency was detected in one-fourth and insufficiency in one-third of children with CMA and other FAs and in those with atopic diseases but no FA, respectively. Vitamin D levels were associated with vitamin D supplementation and consumption of breast milk, cow's milk, infant formula, or plant-based milk beverage, but not with CMA or other FAs. Older children with FA who did not consume any cow's milk or alternative milk beverage were at highest risk for vitamin D insufficiency. Children with CMA have a higher rate of iron deficiency anemia (8%) than children with other FAs (1%) or those with no FA (5%, P < .001); however, suboptimal levels of transferrin saturation and iron were detected in up to one-third of children with CMA or other FAs.

CONCLUSION

Vitamin D deficiency and insufficiency is common in children with atopy overall, but children with CMA are at higher risk for iron deficiency anemia. Intensive nutritional counseling and nutrient intake monitoring, specifically for vitamin D and iron in those avoiding cow's milk, are necessary to optimize nutritional status.

Recognition of food antigens by the mucosal and systemic immune system: Consequences for intestinal development and homeostasis

The impact of nutrition on systemic and intestinal immune responses remains controversially discussed and yet not fully understood. The majority of studies investigating the effects of dietary antigens focused to understand how local and systemic unresponsiveness is induced by innocuous food antigens. Moreover, it has been shown that both, microbial and dietary antigens are essential for the normal development of the mucosal immune system. Based on experimental findings from animals and IBD patients, we propose a model how the intestinal immune system performs the balancing act between recognition and tolerance of dietary antigens at the same time: In the healthy gut, repetitive uptake of dietary antigens by Peyer's patches leads to increasing activation of CD4⁺ T cells till hyper-activated lymphocytes undergo apoptosis. In contrast to healthy controls, this mechanism was disturbed in Crohn's disease patients. This observation might help to better understand beneficial effects of dietary intervention therapy.

Baked egg tolerance: is it possible to predict?

OBJECTIVE

To assess the frequency of baked egg tolerance in IgE-mediated egg allergy patients through the oral food challenge and to assess the tolerance predictability of different skin prick tests, as well as specific serum IgE measurement to egg proteins.

METHODS

In this cross-sectional study, 42 patients with a diagnosis of egg allergy were submitted to different skin prick tests with egg (in natura, boiled, muffin, ovalbumin, and ovomucoid), and specific IgE to egg white, ovalbumin, and ovomucoid; as well as to the oral food challenge with food containing egg, extensively baked in a wheat matrix.

RESULTS

Of the total, 66.6% of patients tolerated the ingestion of egg-containing foods in the oral food challenge. A comparative analysis with positive and negative oral food challenge found no significant differences regarding age, gender, other food allergies, or even specific skin prick tests and IgE values between the groups.

CONCLUSIONS

The study demonstrated an elevated frequency of baked egg food-tolerant individuals among egg allergy patients. None of the tested markers, skin prick tests, or specific IgE, were shown to be good predictors for identifying baked egg-tolerant patients. The oral food challenge with egg baked in a matrix is central to demonstrate tolerance and the early introduction of baked foods, improving patients' and families' quality of life and nutrient intake.

Food allergy management

Optimal management of food allergy is complex and multifaceted. Management of food allergy includes ensuring proper diagnosis, monitoring for the emergence of natural tolerance, screening for nutritional and psychosocial issues, and educating the patient and family on living with food allergies across childhood. Education must encompass successfully avoiding the trigger food, recognizing and treating allergic reactions, and navigating living with food allergies. Allergists can help families prepare for specific situations, such as working with daycares, schools, after-school activities and camps, traveling, and dining out. In addition, psychosocial issues such as anxiety and bullying should be addressed, and counseling with regard to emerging therapies discussed. Managing children with food allergies requires continual follow up with regard to these issues, and the needs of families will change over time. Allergists can guide the family as the child grows and transitions to adulthood when managing food allergy.

Food Allergy: Labelling and exposure risks

In the United States, food allergen labeling is regulated by the U.S. Food and Drug Administration with the implementation of the Food Allergen Labeling and Consumer Protection Act in 2006 that requires packaged foods to clearly indicate the presence of any milk, egg, peanut, tree nuts, wheat, soybeans, fish, and crustacean shellfish. Educating patients and their families how to read food labels includes reading the ingredients list as well as the declaration statement that begins with "Contains." In addition, there is widespread use of precautionary advisory labeling, and patients should be counseled that these precautionary statements are not mandatory and not regulated and, therefore, do not necessarily identify foods with allergen contamination. An allergic reaction to undeclared food allergens as well as complacency with label reading, including precautionary advisory statements, remains a relevant risk for patients with food allergy.

Veganism and paediatric food allergy: two increasingly prevalent dietary issues that are challenging when co-occurring

Vegan diets - defined as the exclusion of all foods of animal origin from the diet- are becoming popular. In recent years, the prevalence of food allergy has also increased, and disproportionately affects children. When vegan diets and food allergy co-occur, this combination can be challenging and pose risks of nutritional deficiencies, particularly during childhood. In this paper, we aim to summarise the major concerns regarding vegan diets and food allergy, review the literature on this topic, and provide some suggestions for healthcare providers, particularly dietitians and nutritionists, who work with food allergic, vegan patients and their family. When working with this patient population, a regular and complete medical nutrition history, including screening for any possible nutritional deficiencies, is warranted. Likewise, the routine tracking of serum markers (especially iodine, iron, zinc, calcium, Vitamins B12, D, B2, and A, selected n-3 fatty acids and protein, which are more abundant in animal vs. plant foods) and symptoms of co-morbid diseases, including asthma, is important, as comorbid diseases may increase energy and nutrient requirements. For infants and children, anthropometry ought to be tracked longitudinally at regular intervals to identify any deviations from the child's previous growth pattern, and to accommodate any increased requirements for growth and development. Correct diagnoses, education and allergy management must be disseminated to the family in a clear and appropriate manner. Children with allergy may have increased nutritional needs due to comorbidity. This is complicated by coincident food allergy and vegan diet as both impose diet restrictions (limiting sources of important nutrients, need for dietary variety and/or increased consumption due to reduced bioavaliability).

Design, quality, safety and efficacy of extensively hydrolyzed formula for management of cow's milk protein allergy: What are the challenges?

Cow's milk protein allergy (CMPA) is one of the most common food allergies in infancy. Clinical food allergy guidelines recommend an extensively hydrolyzed formula (EHF) as the first-line treatment in nonbreastfed infants with CMPA. Designing and commercializing EHF poses both technical and regulatory challenges. Each manufacturing step, from sourcing of raw materials to release of the final product, needs to be managed in accordance with comprehensive quality systems. To avoid cross-contamination via externally sourced ingredients, suppliers should be carefully selected based on quality requirements. Strict zoning of the manufacturing areas according to contamination risk and air flow control are effective strategies to prevent accidental allergen contamination. Furthermore, dedicated manufacturing lines for hypoallergenic products are used to prevent potential cross-contamination from other products produced on the same line. The enzymatic hydrolysis, heat treatment and ultrafiltration used are specific to each manufacturer. Consequently, EHF are a heterogenous group of products with differences in the molecular weight profile of peptides, content of residual immunogenic cow's milk allergens, and residual in-vitro allergenicity. These differences are likely to affect clinical efficacy and safety. As not all commercialized EHF products have undergone formal testing in the laboratory and clinical trials, there is a need to develop guidelines for minimum technical and regulatory requirements for EHF products, including validated assays for ongoing quality control. Clinical trials assessing new EHF products for their hypoallergenicity and ability to support normal growth remain the definitive proof of efficacy and safety in infants and young children with CMPA.

Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders

PURPOSE OF REVIEW

This review presents the available data regarding efficacy of nutritional therapy, highlighting clinical decision points and a strategy for reintroduction of foods following an elemental diet for treatment of eosinophilic gastrointestinal disorders.

RECENT FINDINGS

Elemental and empiric elimination diets are highly effective treatments for eosinophilic gastrointestinal diseases. Standardization in the reintroduction phase, after utilizing the diet for disease remission, is lacking. Clinicians are confronted with multiple challenges regarding the best practice for food reintroduction and identification of potential dietary triggers including order of foods being challenged and duration between endoscopic procedures. Individualization is required for preference and adherence to optimize quality of life and treatment success for this burdensome and life altering immune driven gastrointestinal disorder. Age specific concerns for children, teenagers, and adults should be assessed using a patient centric approach.

Food insecurity and caregiver perceptions of food allergen risk by food purchase location in children with food allergies

Meeting nutritional needs of children with food allergy (FA) may be challenging without affordable, quality foods. Food purchase location may impact availability of FA-safe foods; however, no research examining food purchase location in families of children with FA exists. This study compared caregiver report of food insecurity (FIS; food insecure vs. food secure), FA risk, and history of food-induced anaphylaxis (FIA) in families of children with FA, who primarily purchase food items at grocery/supermarkets (n = 140) or convenience marts/bodegas (CB; n = 32). Caregivers (N = 172; 49% mothers, 49% fathers, 2% grandparent/other relative) of children with FA (57% male; Mage = 7.5 years; 66% White [22% Latinx and 44% non-Latinx] and 23% Black) completed an online survey. Variables included demographics, history of FIA, and caregiver perceptions of FIS and FA risk. Caregivers who purchased food items from CB versus supermarkets reported higher perceived risk of accidental ingestion (χ2 = 20.49, p < .001, 94% vs. 50%), severe reaction (χ2 = 15.05, p < .001, 97% vs. 61%), death (χ2 = 27.48, p < .001, 91% vs. 49%), FIS (χ2 = 21.69, p < .001, 94% vs. 49%), and FIA (χ2 = 11.96, p = .001, 94% vs. 32%). Effect sizes were small-moderate (Cramer's V = .26-.40). Families who purchased food at CB reported greater food allergen concerns and FIS than families who purchased food at supermarkets. Differences in FA-related perceived risks may reflect the health disparity and adversity these families face to meet basic nutritional needs, such as FA-related constraints. Point-of-care efforts are needed to provide early screening for families who may be at risk for experiencing FIS.

Examining Differences in Parent Knowledge About Pediatric Food Allergies

Objective

Pediatric food allergy (FA) is a serious health condition that has become increasingly prevalent. Parents often play a primary role in assessing and managing risk for their child’s FAs, making it critical that they remain informed of the most recent guidelines for FA management. This study aimed to examine if diagnostic source (i.e., pediatrician vs. allergist) and child- and parent-level variables predicted parental FA knowledge using a comprehensive measure.

Methods

The Food Allergy Knowledge Test (FAKT) was administered to parents (N = 518) of children aged 3–17 years with (n = 349) and without (n = 169; i.e., control group) FAs using internet-sampling procedures. The sample was further partitioned into parents of children diagnosed by an allergist or a pediatrician, and control group parents who did or did not endorse knowing someone with an FA.

Results

Significant group differences were found with respect to the overall FAKT score and diagnostic source. Among the FA group, parental relationship to child, income, identification with a minority status, parental anxiety, and child possession of an emergency action plan were significant predictors of FAKT scores.

Conclusions

Knowledge of FA was poor across all groups. Education for caregivers both with and without food-allergic children is important to ensure FA safety in multiple settings. Future directions and limitations are discussed.

The use of amino acid-based nutritional feeds is effective in the dietary management of pediatric eosinophilic oesophagitis

INTRODUCTION

Eosinophilic oesophagitis (EoE) is an immune-mediated, chronic disease characterized by eosinophilic inflammation and esophageal dysfunction. Specific food allergens including cow's milk protein, are partially causative to disease progression, and dietary management forms three main options; the elemental diet (ED), the empirical elimination diet (EED), and the targeted elimination diet (TED). The dietary choice should be individualized, however, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines recommend an ED for pediatric EoE with multiple food allergies, failure to thrive, unresponsive disease or unable to follow a highly restricted diet. The aim of this narrative review was to explore the effectiveness of the ED (using amino acid formula [AAF]), in the management of pediatric EoE.

METHODS

Literature searches were performed to identify eligible studies that described outcomes including eosinophil count, clinical symptoms, growth, and medications.

RESULTS

Overall, 10 eligible studies were found, with n = 462 patients assigned to receive AAF from a total of n = 748 (average age 6.7 years), for a duration of 4 to 8 weeks. The use of AAF reduced eosinophil levels and demonstrated remission (defined as ≤10 eosinophils per high power field) in 75%-100% of children with improvements, if not resolution, in clinical symptoms. AAF was more clinically effective than the use of the EED or TED, where remission rates were 75%-81% and 40%-69%, respectively. Few studies collected growth outcomes, however where documented these were positive for those on AAF. The long-term impacts of each diet were not thoroughly explored.

CONCLUSIONS

The use of AAF is a clinically effective management option for pediatric EoE, and further research is required to guide long-term management.

Cow's Milk Substitutes for Children: Nutritional Aspects of Milk from Different Mammalian Species, Special Formula and Plant-Based Beverages

Cow's milk and dairy are commonly consumed foods in the human diet and contribute to maintaining a healthy nutritional state, providing unique sources of energy, calcium, protein, and vitamins, especially during early childhood. Milk formula is usually made from cow's milk and represents the first food introduced into an infant's diet when breastfeeding is either not possible or insufficient to cover nutritional needs. Very recently, increased awareness of cow's milk protein allergy and intolerance, and higher preference to vegan dietary habits have influenced parents towards frequently choosing cows' milk substitutes for children, comprising other mammalian milk types and plant-based milk beverages. However, many of these milk alternatives do not necessarily address the nutritional requirements of infants and children. There is a strong need to promote awareness about qualitative and quantitative nutritional compositions of different milk formulas, in order to guide parents and medical providers selecting the best option for children. In this article, we sought to review the different compositions in terms of macronutrients and micronutrients of milk from different mammalian species, including special milk formulas indicated for cow's milk allergy, and of plant-based milk alternatives.

Confirmed Hypoallergenicity of a Novel Whey-Based Extensively Hydrolyzed Infant Formula Containing Two Human Milk Oligosaccharides

BACKGROUND

We sought to determine whether an extensively hydrolyzed formula (EHF) supplemented with two human milk oligosaccharides (HMO) was tolerated by infants with cow's milk protein allergy (CMPA).

METHODS

A whey-based EHF (Test formula) containing 2'fucosyl-lactose (2'FL) and lacto-N-neotetraose (LNnT) was assessed for clinical hypoallergenicity and safety. The Control formula was a currently marketed EHF without HMO. Children with CMPA, aged 2 months to 4 years, were assessed by double-blind, placebo-controlled food challenges (DBPCFC) to both formulas, in randomized order. If both DBPCFC were negative, subjects participated in a one-week, open food challenge (OFC) with the Test formula. Symptoms and adverse events were recorded. Hypoallergenicity was accepted if at least 90% (with 95% confidence intervals) of subjects tolerated the Test formula.

RESULTS

Of the 82 children with CMPA that were screened, 67 (intention-to-treat [ITT] cohort-mean age 24.5 ± 13.6 months; range 2-57; 45 [67.2%] male) were randomized to receive either the Test or the Control formula during the first DBPCFC. Of these, 64 children completed at least one DBPCFC (modified intention-to-treat [mITT] cohort). Three children were excluded due to protocol deviations (per protocol [PP] cohort; n = 61). There was one allergic reaction to the Test, and one to the Control formula. On the mITT analysis, 63 out of 64 (98.4%; 95% CI lower bound 92.8%), and on the PP analysis 60 out of 61 (98.4%; 95% CI lower bound 92.5%) participants tolerated the Test formula, confirming hypoallergenicity.

CONCLUSION

The whey-based EHF supplemented with 2'FL and LNnT met the clinical hypoallergenicity criteria and can be recommended for the management of CMPA in infants and young children.

Intestinal development and homeostasis require activation and apoptosis of diet-reactive T cells

The impact of food antigens on intestinal homeostasis and immune function is poorly understood. Here, we explored the impact of dietary antigens on the phenotype and fate of intestinal T cells. Physiological uptake of dietary proteins generated a highly activated CD44+Helios+CD4+ T cell population predominantly in Peyer patches. These cells are distinct from regulatory T cells and develop independently of the microbiota. Alimentation with a protein-free, elemental diet led to an atrophic small intestine with low numbers of activated T cells, including Tfh cells and decreased amounts of intestinal IgA and IL-10. Food-activated CD44+Helios+CD4+ T cells in the Peyer patches are controlled by the immune checkpoint molecule PD-1. Blocking the PD-1 pathway rescued these T cells from apoptosis and triggered proinflammatory cytokine production, which in IL-10-deficient mice was associated with intestinal inflammation. In support of these findings, our study of patients with Crohn's disease revealed significantly reduced frequencies of apoptotic CD4+ T cells in Peyer patches as compared with healthy controls. These results suggest that apoptosis of diet-activated T cells is a hallmark of the healthy intestine.

The Role of Elimination Diets in Atopic Dermatitis-A Comprehensive Review

BACKGROUND/OBJECTIVES

Diet is a common concern for individuals with atopic dermatitis (AD) and their families. Studies regarding the effect of dietary interventions on AD exist, but many are limited by small size and poor design. Conflicting results present a challenge to clinicians seeking to counsel patients. The aim of the current review is to examine the published literature and generate helpful conclusions for clinicians faced with dietary questions in AD.

METHODS

A PubMed search was performed focusing on dietary interventions for AD in children and adults through July 2016. The search was limited to the English language and included studies that evaluated one or more forms of dietary modification for the treatment of AD. Studies of supplementation, such as with vitamins, minerals, or probiotics, were not included, nor were studies on prevention of the development of AD. A total of 43 articles met the inclusion criteria and were included in the final analysis.

RESULTS

Trials varied in type, duration, and the AD patient populations studied. Overall, there is some level I evidence to support specific exclusion diets in preselected patients but insufficient evidence for strict elimination diets (diets that are typically limited to six to eight foods). Data supporting other interventions are mixed and based on small, poorly designed studies.

CONCLUSIONS

A comprehensive literature review reveals some promising results and several areas in need of further study. More evidence is needed to form a strong foundation for recommendations regarding the utility and role of elimination diets in AD management, but current evidence suggests that strict diet management is not effective in the treatment AD in the vast majority of patients.

Prevalence of food allergy in infants and pre-schoolers in Brazil

BACKGROUND

Food allergy is an increasing problem in public health, especially in childhood. Its incidence has increased in the last decade. Despite this, estimates of the actual incidence and prevalence are uncertain. The aim of this study was to estimate the prevalence of food allergy in infants and pre-schoolers.

METHODS

The parents of 3897 children completed questionnaires on the occurrence of any reaction to food. Children with parentally reported reactions were selected for further examination including a clinical interview, physical examination, allergic tests, and if necessary, oral food challenge to conclude the diagnosis of FA.

RESULTS

The estimated prevalence of allergy in children aged 4-59 months was 0.61%, being, 1.9% in infants and 0.4% in pre-schoolers. Among the 604 patients physicians evaluated with parent-reported FA, 24 (4%) had a confirmed diagnosis of food allergy, and 580 (96%) were excluded in the remaining. Of these, approximately half (51/52.6%) of 97 infants and (128/48%) of 487 pre-schoolers already performed the diet exclusion suspected food for a period of time.

CONCLUSION

This study shows that high overall prevalence of parental belief of current food allergy however the same was not observed in the in physician-diagnosed food allergy. The prevalence of food allergy was lower than that observed in the literature. This study alerts health professionals to the risk entailed by overestimation of cases of food allergy and unnecessary dietary exclusion, which may result in impairment in growth and development of children, especially in their first years of life.

Advances in the Treatment of Food Allergy: Sublingual and Epicutaneous Immunotherapy

Food allergies continue to increase in prevalence. Standard care is a strict elimination diet, but life-threatening reactions still occur. Allergen immunotherapy has the most potential in treating food allergy. Subcutaneous immunotherapy has not been adopted into food allergy therapy. Oral immunotherapy has a high rate of adverse reactions. Sublingual immunotherapy (SLIT) uses the tolerogenic environment of the oral mucosa and epicutaneous immunotherapy (EPIT) uses the immune cells of the epidermis to transport antigens to afferent lymph nodes to activate immune responses. SLIT and EPIT can successfully desensitize patients. More research is needed to define optimal doses and administration protocols.

The impact of the elimination diet on growth and nutrient intake in children with food protein induced gastrointestinal allergies

Background

Non immunoglobulin E (IgE) mediated allergies affecting the gastrointestinal tract require an elimination diet to aid diagnosis. The elimination diet may entail multiple food eliminations that contribute significantly to macro- and micro-nutrient intake which are essential for normal growth and development. Previous studies have indicated growth faltering in children with IgE-mediated allergy, but limited data is available on those with delayed type allergies. We therefore performed a study to establish the impact on growth before and after commencing an elimination diets in children with food protein induced non-IgE mediated gastrointestinal allergies.

Methods

A prospective, observational study was performed at the tertiary gastroenterology department. Children aged 4 weeks–16 years without non-allergic co-morbidities who were required to follow an elimination diet for suspected food protein induced gastrointestinal allergies were included. Growth parameters pre-elimination were taken from clinical notes and post-elimination measurements (weight and height) were taken a minimum of 4 weeks after the elimination diet. A 3-day estimated food diary was recorded a minimum of 4 weeks after initiating the elimination diet, including also any hypoallergenic formulas or over the counter milk alternatives that were consumed.

Results

We recruited 130 children: 89 (68.5 %) boys and a median age of 23.3 months [IQR 9.4–69.2]. Almost all children (94.8 %) in this study eliminated CM from their diet and average contribution of energy in the form of protein was 13.8 % (SD 3.9), 51.2 % (SD 7.5) from carbohydrates and 35 % (SD 7.5) from fat. In our cohort 9 and 2.8 % were stunted and wasted respectively. There was a statistically significant improvement in weight-for-age (Wtage) after the 4 week elimination diet. The elimination diet itself did not improve any of the growth parameters, but achieving energy and protein intake improved Wtage and WtHt respectively, vitamin and/or mineral supplements and hypoallergenic formulas were positively associated with WtHt and Wtage.

Conclusion

With appropriate dietary advice, including optimal energy and protein intake, hypoallergenic formulas and vitamins and mineral supplementation, growth parameters increased from before to after dietary elimination. These factors were positively associated with growth, irrespective of the type of elimination diet and the numbers of foods eliminated.

EAACI Molecular Allergology User's Guide

The availability of allergen molecules ('components') from several protein families has advanced our understanding of immunoglobulin E (IgE)-mediated responses and enabled 'component-resolved diagnosis' (CRD). The European Academy of Allergy and Clinical Immunology (EAACI) Molecular Allergology User's Guide (MAUG) provides comprehensive information on important allergens and describes the diagnostic options using CRD. Part A of the EAACI MAUG introduces allergen molecules, families, composition of extracts, databases, and diagnostic IgE, skin, and basophil tests. Singleplex and multiplex IgE assays with components improve both sensitivity for low-abundance allergens and analytical specificity; IgE to individual allergens can yield information on clinical risks and distinguish cross-reactivity from true primary sensitization. Part B discusses the clinical and molecular aspects of IgE-mediated allergies to foods (including nuts, seeds, legumes, fruits, vegetables, cereal grains, milk, egg, meat, fish, and shellfish), inhalants (pollen, mold spores, mites, and animal dander), and Hymenoptera venom. Diagnostic algorithms and short case histories provide useful information for the clinical workup of allergic individuals targeted for CRD. Part C covers protein families containing ubiquitous, highly cross-reactive panallergens from plant (lipid transfer proteins, polcalcins, PR-10, profilins) and animal sources (lipocalins, parvalbumins, serum albumins, tropomyosins) and explains their diagnostic and clinical utility. Part D lists 100 important allergen molecules. In conclusion, IgE-mediated reactions and allergic diseases, including allergic rhinoconjunctivitis, asthma, food reactions, and insect sting reactions, are discussed from a novel molecular perspective. The EAACI MAUG documents the rapid progression of molecular allergology from basic research to its integration into clinical practice, a quantum leap in the management of allergic patients.

Food Allergy in childhood: phenotypes, prevention and treatment

The prevalence of food allergy in childhood increased in the last decades, especially in Westernized countries where this phenomenon has been indicated as a second wave of the allergic epidemic. In parallel, scientific interest also increased with the effort to explain the reasons of this sudden rise and to identify potential protective and risk factors. A great attention has been focused on early exposures to allergenic foods, as well as on other nutritional factors or supplements that may influence the immune system in a positive direction. Both interventions on maternal diet before birth or during breastfeeding and then directly on infant nutrition have been investigated. Furthermore, the natural history of food allergy also seems to be changing over time; IgE-mediated cow's milk allergy and egg allergy seem to be more frequently a persistent rather than a transient disease in childhood, as described in the last years. Food avoidance and the emergency drugs in case of an adverse event, such as epinephrine self-injector, are currently the first-line treatment in patients with food allergies, with a resulting impairment in the quality of life and social behaviour. During the last decade, oral immunotherapy emerged as an optional treatment with remarkable results, offering a novel perspective in the treatment for and management of food allergy.

Oral immunotherapy for food allergy: mechanisms and role in management

With the emergence of food allergy as an important public health problem, it has become clear that there is an unmet need in regard to treatment. In particular, IgE-mediated food allergy that is associated with risk of fatal anaphylaxis has been the subject of multiple studies in the past decade. The growing body of evidence derived from multiple centres and various study designs indicates that for IgE-mediated food allergy, immunomodulation through food immunotherapy is possible; however, the extent of protection afforded by such treatment is highly variable. At this time, the capacity for food immunotherapy to restore permanent tolerance to food has not been demonstrated conclusively. This review will discuss these topics as they apply to the most important studies of food oral immunotherapy.

Allergy-test-driven elimination diet is useful in children with eosinophilic esophagitis, regardless of the severity of symptoms

BACKGROUND

A combination of PPIs and corticosteroids is the pharmacotherapy mostly used to treat eosinophilic esophagitis (EoE), while dietetic manipulations consist also an efficient option. The aim of this study was to compare the efficacy of allergy-test-driven elimination diet in children with mild symptoms of EoE to a group of children with moderate/severe symptoms.

METHODS

Thirty-five children, aged 7 months to 12 yr, with EoE were enrolled in the study. They had a clinical history of GERD-like (21 children, Group A) or more severe symptoms (14 children, Group B). The diagnosis had been confirmed after two preliminary months of therapy with PPIs and an esophagogastroduodenoscopy. Soon after diagnosis, they were allergy-tested, using IgE detection (SPT and serum-specific IgE) and atopy patch tests (APTs). A 12-month tailor-made diet was prescribed according to the tests. Patients of Group B continued PPIs for two more months, while swallowed topical steroids were also prescribed to them for the first 5 months after diagnosis, followed by an 'as-needed' use of them for the rest of the study. Endoscopy was repeated at the end of the study.

RESULTS

Milk and egg were the most common APT-positive allergens. Thirty-two patients were instructed to follow an elimination diet, which was completed by 15/18 of Group A and 12/14 of Group B. An improvement of symptoms was reported by 26/27 patients that completed the study. The use of swallowed corticosteroids was noticeably decreased during the as-needed period, in Group B. A remarkable reduce of eosinophils was noticed in biopsies; from 42.84 ± 18.08, they decreased to 6.41 ± 3.20, a year after.

CONCLUSION

All children with EoE and mild symptoms had resolution of symptoms and normal eosinophils in the esophageal mucosa a year after an allergy-driven elimination diet. Patients with moderate/severe EoE symptoms had the same improvement, indicating that an elimination diet is an efficient complementary treatment to corticosteroids.

The impact of dietary therapy on clinical and biologic parameters of pediatric patients with eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a clinicopathologic disease that presents with a massive infiltration of the esophagus by eosinophils triggered by food antigen(s).

OBJECTIVE

To determine the impact of dietary therapy on nutritional parameters in patients who present with EoE.

METHODS

A convenience retrospective study analyzed patients with EoE after a 2-month dietary therapy (6-food elimination diet, avoidance of the 6 most common allergenic foods, plus avoidance of those eliciting positive skin testing, plus amino-acid formula as replacement for dairy products). Pre- and postdiet allergic and nutritional status were evaluated.

RESULTS

Of 111 eligible patients, 59 patients, with a median age of 77.7 months (range, 9-189 months) were enrolled. Dietary therapy significantly increased the return to normal endoscopic appearance (47.4%, P < .0009) and led to complete remission (<5 eosinophils/esophageal HPF and disappearance of symptoms) in 59.3%. All symptoms improved, digestive (98.3%), cutaneous (80%), and respiratory (92.8%). The prediet median weight-for-height (WFH) z score was -0.75 (-3.00 to 5.69), and the postdiet WFH did not significantly differ, -0.51 (-3.09 to 5.00). The prediet WFH z score was less than -2 (moderate malnutrition) in 10.1%. Postdiet blood eosinophils counts decreased in absolute numbers and in counts ≥ 500 × 10(6)/L (P < .0001). Evaluation after 1 year of progressive reintroduction of eliminated foods was available in 33 children: the median WFH z score did not significantly improve, from -0.89 (range, -3.00 to 0.67) at enrollment to -0.59 (range, -3.66 to 2.24).

CONCLUSION

The nutritional status of children with EoE was mildly affected and not worsened by the 2-month dietary therapy.

Food protein-induced enterocolitis syndrome and allergic proctocolitis

Non-IgE-mediated food allergic disorders account for up to 40% of milk protein allergy in infants and young children. We aim to review the recent literature and to provide an update on diagnosis and management of food protein-induced enterocolitis syndrome (FPIES) and food protein-induced allergic proctocolitis (FPIAP). The peer-reviewed articles indexed in PubMed have been reviewed. FPIES manifests in infants as profuse, repetitive vomiting and lethargy, often with diarrhea, leading to acute dehydration, or weight loss and failure to thrive, in chronic form. FPIES is caused most commonly by cow's milk (CM) and soy proteins; rice, oat, and other solid foods may also trigger FPIES. FPIES rarely occurs in the exclusively breastfed infants. FPIES is underrecognized; children are often mismanaged as having acute viral gastrointestinal illness, sepsis, or surgical disease, delaying diagnosis of FPIES for many months. Approximately 25% of children with FPIES develop food-specific IgE antibodies and some transition to immediate food allergy; IgE positivity is associated with a more protracted course. FPIES is a self-limiting condition, with most cases resolving by age three to five years. Ondansetron may be helpful in managing acute FPIES. FPIAP is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. Up to 60% of cases occur in exclusively breastfed infants and resolve with maternal elimination of CM and soy proteins. The majority of cases resolve by age 12 months. FPIES may transition to IgE-mediated food allergy in some patients; IgE positivity to the FPIES food is a marker of a more persistent disease. FPIAP is benign and resolves by age 12 months in most patients.

Relationship between physique and food avoidance in infants: a study conducted in a community setting in Japan

The relationship between food avoidance during infancy and the growth of Japanese infants in a community health setting has not been well evaluated. In order to assess the growth of infants who avoided either of the three major allergen foods in Japan, eggs, milk or wheat, we employed the results of 4 physical checkups recorded in maternity passbooks and administrated a questionnaire on allergic diseases, height and weight at birth to the guardians of 1,132 infants at the age of 3.5 years. Data was obtained from 890 subjects (78.6%) and 662 subjects (58.5%) who met the inclusion criteria were analyzed. The height, weight and body mass index percentile scores of each subject were calculated. Subjects who avoided either of the three foods at 3.5 years had lower weight percentile scores at 1.5 years, lower height and weight percentile scores at 3.5 years, and lower weight growth rates, compared with the subjects who did not avoid any of the three foods at 3.5 years (P=0.02, 0.03, 0.03, 0.01). The results suggested that there was a negative relationship between physique and food avoidance in infants, and that physical and nutritional assessments are important for food avoiders.

A practical approach to vitamin and mineral supplementation in food allergic children

Background

The management of food allergy in children requires elimination of the offending allergens, which significantly contribute to micronutrient intake. Vitamin and mineral supplementation are commonly suggested as part of dietary management. However a targeted supplementation regime requires a complete nutritional assessment, which includes food diaries. Ideally these should be analysed using a computerised program, but are very time consuming. We therefore set out to evaluate current practice of vitamin and mineral supplementation in a cohort of children with non-Immunoglobulin E (IgE) mediated food allergies.

Methods

This prospective, observational study recruited children aged 4 weeks – 16 years, who required to follow an elimination diet for non-IgE mediated allergies. Only children that improved according to a symptom score and were on a vitamin and/or mineral supplement were included. A 3-day food diary including vitamin and mineral supplementation was recorded and analysed using Dietplan computer program. We assessed dietary adequacy with/without the supplement using the Dietary Reference Values.

Results

One hundred-and-ten children had completed food diaries and of these 29% (32/110) were taking vitamin and/or mineral supplements. Children on hypoallergenic formulas were significantly (p = 0.007) less likely to be on supplements than those on alternative over-the-counter milks. Seventy-one percent had prescribable supplements, suggested by a dietitian/physician. Sixty percent of those without a vitamin supplement had a low vitamin D intake, but low zinc, calcium and selenium was also common. Of the supplemented cohort many continued to be either under or over-supplemented.

Conclusion

This study has raised the question for the first time, whether clinicians dealing with paediatric food allergies should consider routine vitamin and/or mineral supplements in the light of deficient intake being so common in addition to being so difficult to predict.

Impact of elimination diets on growth and nutritional status in children with multiple food allergies

BACKGROUND

Impairment of growth has been reported in food-allergic children. It is not known whether this is related to the extent of food allergies. We sought to compare growth, nutritional status, and nutrient intake in children with food allergy either avoiding cow's milk or avoiding cow's milk and wheat, which are staples of the diet in young children.

METHODS

Infants and young children with challenge-proven allergy were recruited to this prospective study. They were strictly avoiding their allergic food triggers, either cow's milk, or cow's milk and wheat. They were counseled by a dietitian specialized in food allergies on food avoidance diets and nutritionally adequate supplementation at regular intervals. A 3-day food diary was kept. Children's height, weight, and laboratory data for nutritional parameters were monitored at 8-month intervals.

RESULTS

A total of 18 patients avoiding milk and 28 patients avoiding milk and wheat were evaluated at an average of 12, 21, and 28 months of age. During the follow-up, the markers of nutritional status, nutrient intake or height for age, and weight for height were comparable between the two groups, although the means for anthropometric measures were below the average for age in both groups.

CONCLUSIONS

The extent of food elimination diet has no impact on growth or nutritional status of food-allergic children, when diet is adequately supplemented. Close physician and dietitian follow-up are essential for food-allergic children when avoiding one or more foods, which are staples of the diet.

The development of a standardised diet history tool to support the diagnosis of food allergy

The disparity between reported and diagnosed food allergy makes robust diagnosis imperative. The allergy-focussed history is an important starting point, but published literature on its efficacy is sparse. Using a structured approach to connect symptoms, suspected foods and dietary intake, a multi-disciplinary task force of the European Academy of Allergy and Clinical Immunology developed paediatric and adult diet history tools. Both tools are divided into stages using traffic light labelling (red, amber and green). The red stage requires the practitioner to gather relevant information on symptoms, atopic history, food triggers, foods eaten and nutritional issues. The amber stage facilitates interpretation of the responses to the red-stage questions, thus enabling the practitioner to prepare to move forward. The final green stage provides a summary template and test algorithm to support continuation down the diagnostic pathway. These tools will provide a standardised, practical approach to support food allergy diagnosis, ensuring that all relevant information is captured and interpreted in a robust manner. Future work is required to validate their use in diverse age groups, disease entities and in different countries, in order to account for differences in health care systems, food availability and dietary norms.

Diagnosis and treatment of pediatric food allergy: an update

The prevalence of pediatric food allergy and anaphylaxis has increased in the last decades, especially in westernized countries where this emerging phenomenon was marked as a "second wave" of the allergic epidemic. Over recent years great advances have been achieved in the field of in vitro allergy testing and component-resolved diagnosis has increasingly entered clinical practice. Testing for allergen components can contribute to a more precise diagnosis by discriminating primary from cross-reactive sensitizations and assessing the risk of severe allergic reactions.The basic concept of the management of food allergy in children is also changing. Avoidance of the offending food is still the mainstay for disease management, especially in primary health care settings, but it severely affects the patients' quality of life without reducing the risk of accidental allergic reactions. There is a growing body of evidence to show that specific oral tolerance induction can represent a promising treatment option for food allergic patients. In parallel, education of food allergic patients and their caregivers as well as physicians about anaphylaxis and its treatment is becoming recognized a fundamental need. International guidelines have recently integrated these new evidences and their broad application all over Europe represents the new challenge for food allergy specialists.

Review article: the diagnosis and management of food allergy and food intolerances

BACKGROUND

Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public.

AIM

To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children.

METHODS

MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance.

RESULTS

An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4-7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1-2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described.

CONCLUSIONS

Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.

Nutritional management of food protein-induced enterocolitis syndrome

PURPOSE OF REVIEW

To summarize the latest information on the nutritional management of food protein-induced enterocolitis syndrome (FPIES), focusing on the foods implicated and how to avoid these whilst maintaining a nutritionally sound diet.

RECENT FINDINGS

A number of foods are implicated in FPIES such as milk, soy and grains, particularly rice. The number of foods implicated in FPIES per individual differs, but the majority of reported cases have two or fewer food triggers involved.

SUMMARY

FPIES is a complex presentation of non-IgE-mediated food allergy. Dietary management is complicated as both common food allergens as well as atypical food allergens can trigger FPIES. Sound nutritional advice is required to ensure appropriate food avoidance, adequate consumption of other foods and sufficient nutritional intake to maintain and ensure growth and development.

A thickened amino-acid formula in infants with cow's milk allergy failing to respond to protein hydrolysate formulas: a randomized double-blind trial

INTRODUCTION

Amino-acid-based formulas (AAFs) are recommended for children with cow's milk protein allergy (CMPA) failing to respond to extensively hydrolyzed formulas (eHFs).

OBJECTIVE

This study aimed to assess the tolerance/hypoallergenicity and efficacy of a thickened AAF (TAAF) in these infants.

METHODS

This multicenter, double-blind, randomized controlled trial (NCT01940068) compared 3-month feeding with a pectin-based TAAF (Novalac(®), United Pharmaceuticals, Paris, France) and a commercially available "reference" AAF (RAAF; Neocate(®), Nutricia, Germany) in infants aged <18 months with CMPA and persistent allergy symptoms with eHF feeding. Reported here are the results of an interim analysis after 1 month of feeding.

RESULTS

Of the 86 infants randomized, CMPA with eHF intolerance was confirmed in 75 infants; all of them tolerated the allocated AAFs. The major allergic symptom disappeared within 1 month in 61.9 and 51.5 % and regurgitations disappeared in 66.7 and 42.3 % of infants who received TAAF and RAAF, respectively. Infants had significantly more normal stools (soft or formed consistency) with the TAAF (90.5 vs. 66.7 %; p = 0.011). From baseline, daily family life significantly improved with both AAFs: crying time decreased by 97.3 (p < 0.001) and 28.6 min (p = 0.014) and sleeping time increased by 64.6 (p = 0.009) and 29.0 min with TAAF and RAAF, respectively. At day 30, weight and body mass index z-score gains were 0.1 and 0.2 with TAAF and 0.2 and 0.0 with RAAF.

CONCLUSION

Both AAFs were well tolerated by infants with CMPA and eHF intolerance and ensured appropriate growth, with the TAAF providing additional comfort.

Diet in dermatology: Part I. Atopic dermatitis, acne, and nonmelanoma skin cancer

Patients commonly inquire about dietary modifications as a means to prevent or manage skin disease. Answering these questions is often challenging, given the vast and conflicting evidence that exists on this topic. This 2-part continuing medical education article summarizes the evidence to date to enable physicians to answer patients' questions in an evidence-based manner. Part I includes atopic dermatitis, acne, and nonmelanoma skin cancer. The role of dietary supplementation, dietary exclusion, food allergy, maternal diet, and breastfeeding in the development and/or prevention of atopic dermatitis is summarized. The dermatoendocrinologic mechanism for the effects of glycemic index/glycemic load and milk on acne is described, as well as related clinical evidence for dietary modifications. Finally, evidence and recommendations for restriction or supplementation of dietary factors in the prevention of nonmelanoma skin cancer, including fat, vitamins A, C, D, and E, and selenium, are reported.

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.

Dietary elimination of children with food protein induced gastrointestinal allergy - micronutrient adequacy with and without a hypoallergenic formula?

Background

The cornerstone for management of Food protein-induced gastrointestinal allergy (FPGIA) is dietary exclusion; however the micronutrient intake of this population has been poorly studied. We set out to determine the dietary intake of children on an elimination diet for this food allergy and hypothesised that the type of elimination diet and the presence of a hypoallergenic formula (HF) significantly impacts on micronutrient intake.

Method

A prospective observational study was conducted on children diagnosed with FPIGA on an exclusion diet who completed a 3 day semi-quantitative food diary 4 weeks after commencing the diet. Nutritional intake where HF was used was compared to those without HF, with or without a vitamin and mineral supplement (VMS).

Results

One-hundred-and-five food diaries were included in the data analysis: 70 boys (66.7%) with median age of 21.8 months [IQR: 10 - 67.7]. Fifty-three children (50.5%) consumed a HF and the volume of consumption was correlated to micronutrient intake. Significantly (p <0.05) more children reached their micronutrient requirements if a HF was consumed. In those without a HF, some continued not to achieve requirements in particular for vitamin D and zinc, in spite of VMS.

Conclusion

This study points towards the important micronutrient contribution of a HF in children with FPIGA. Children, who are not on a HF and without a VMS, are at increased risk of low intakes in particular vitamin D and zinc. Further studies need to be performed, to assess whether dietary intake translates into actual biological deficiencies.

Immunotherapy - risk/benefit in food allergy

Food allergy is a growing health concern in the westernized world with approx. 6% of children suffering from it. A lack of approved treatment has led to strict avoidance of the culprit food proteins being the only standard of care. Nowadays in-depth research is conducted to evaluate the possible use of allergen-specific immunotherapy (SIT) as an active therapeutic option for food allergy. Various routes of administration for the immunotherapy are investigated, including subcutaneous, oral, sublingual, and epicutaneous, and some appear to be successful in inducing a temporary tolerant state. Most research has been conducted with oral immunotherapy due to its efficacious and relatively safe profile. Increasing interest is dedicated to safer and more convenient approaches, such as sublingual and epicutaneous SIT; however, doubts exist about their possible capacity to induce temporary tolerant state and permanent oral tolerance. The high frequency of allergic adverse reactions of the various approaches and the inability to achieve permanent oral tolerance have highlighted the need of refinements in the strategies. A promising strategy for preventing IgE cross-linking and thus enhancing safety of SIT, while still activating T cells, is the use of tolerogenic peptides. The implementation of such an immunotherapy approach has the potential of not only increasing the chance of achieving a permanent state of tolerance, but also improving the safety and tolerability of the therapy. Immunotherapy for food allergy is still not ready for the clinic, but current and upcoming studies are dedicated to collect enough evidence for the possible implementation of allergen-SIT as a standard treatment for food allergy.

How to reintroduce cow's milk?

In a child that is allergic to milk, the natural next step, following the elimination diet, is the reintroduction of cow's milk. Several questions may arise. When feasible, this reintroduction has many benefits for the child and his family. However, the disease needs to be well defined by physicians and explained to parents. They need to understand that there are different types of allergy to cow's milk, specifically IgE- and non-IgE-mediated, and each of these may exhibit both a variable duration and frequently an incomplete recovery. Deciding where to first reintroduce cow's milk to a child who has previously followed a milk-free diet, whether it be at home or in a hospital, also frequently presents an issue. Following this first reintroduction, the progressive increase of milk into the diet needs to be managed properly, as not all children will go back to a normal dairy products intake. Recent studies show that most children with milk allergy tolerate products containing baked milk and that their consumption might speed up recovery. Hence, the purpose of the milk challenge in a child on a milk-free diet is becoming, even in a child still reactive to milk, the first step of gradual and individually adapted reintroduction of milk or dairy products. When reintroduction of cow's milk does not work, immunotherapy becomes an option, and this is carried out in specialized centers.

Diagnosis and management of non-IgE-mediated cow's milk allergy in infancy - a UK primary care practical guide

The UK NICE guideline on the Diagnosis and Assessment of Food Allergy in Children and Young People was published in 2011, highlighting the important role of primary care physicians, dietitians, nurses and other community based health care professionals in the diagnosis and assessment of IgE and non-IgE-mediated food allergies in children. The guideline suggests that those with suspected IgE-mediated disease and those suspected to suffer from severe non-IgE-mediated disease are referred on to secondary or tertiary level care. What is evident from this guideline is that the responsibility for the diagnostic food challenge, ongoing management and determining of tolerance to cow’s milk in children with less severe non-IgE-mediated food allergies is ultimately that of the primary care/community based health care staff, but this discussion fell outside of the current NICE guideline. Some clinical members of the guideline development group (CV, JW, ATF, TB) therefore felt that there was a particular need to extend this into a more practical guideline for cow’s milk allergy. This subset of the guideline development group with the additional expertise of a paediatric gastroenterologist (NS) therefore aimed to produce a UK Primary Care Guideline for the initial clinical recognition of all forms of cow’s milk allergy and the ongoing management of those with non-severe non-IgE-mediated cow’s milk allergy in the form of algorithms. These algorithms will be discussed in this review paper, drawing on guidance primarily from the UK NICE guideline, but also from the DRACMA guidelines, ESPGHAN guidelines, Australian guidelines and the US NIAID guidelines.