Nutritional aspects in diagnosis and management of food hypersensitivity-the dietitians role

Nutritional and Psychosocial Impact of Food Allergy in Pediatric Age

Treatment of IgE-mediated food allergy involves avoiding the food causing the allergic reaction. In association, an action plan for allergic reactions is indicated, sometimes including self-injectable adrenaline. In addition to these dietary and medical implications, there are two equally important ones: nutritional and psychosocial. From a nutritional point of view, it is known that children suffering from food allergy have a growth delay in height and weight compared to their non-allergic peers. Specifically, this condition is directly related to the specific food excluded from the diet, the number of foods excluded and the duration of the elimination diet. From a psychosocial point of view, the child often cannot eat the foods other guests eat. Children with food allergy may perceive an aura of parental anxiety around their mealtime and may be afraid that what they eat could have harmful consequences for their health. Furthermore, children's and their parents' quality of life appears to be affected. The need to manage the allergy and the nutritional and psychosocial problems positions the pediatric nutritionist and the child neuropsychiatrist as support figures for the pediatric allergist in managing the child with food allergy.

Comprehensive Care and Education Can Improve Nutritional and Growth Outcomes in Children with Persistent Cow's Milk, Egg, or Peanut Allergies: A Five-Year Follow-Up Study of Nutritional Status

BACKGROUND

Data suggest that food allergies greatly impact a child's health and growth due to inadequate nutrient intake. Our study aimed to establish the long-term outcome of children with food allergies compared to a control group.

METHODS

This study was a retrospective cohort study with longitudinal follow-up with a mean period of 4.85 years from the diagnosis to the last study visit. The patients' nutritional intake was assessed using a three-day food diary and analysed by a dietitian. Patients (61 boys and 33 girls, mean age 6.9 years) had a single food allergy including 21 patients with cow's milk, 34 with egg, and 39 with peanut allergies. The control group included 36 children (19 boys and 17 girls, mean age 8.03 years). Blood analysis was performed on all participants.

RESULTS

Data from our study showed that patients with cow's milk, egg or peanut allergies had normal growth and achieved catch-up growth from the diagnosis until the last study visit. In the cow's milk allergy group, the allergy was shown to affect calcium intake (p < 0.05), while egg and peanut allergies did not impact the dietary intake of nutrients. None of the investigated food allergies affected blood results (p < 0.05).

CONCLUSIONS

In the present study, we showed that single food allergies do not compromise growth in children if they are provided with appropriate support and that the affected children reach catch-up growth from the diagnosis.

Awareness of Food Allergies and Allergens on the Menus of Restaurants and Cafes among Saudi Female University Students

Exposure to allergens could be life-threatening for people with food allergies. Restaurants and cafes are challenging environments for accommodating food allergies. This study aimed to measure King Saud University female students' awareness about food allergens on restaurants' and cafes' menus. This cross-sectional study was conducted on 379 students aged 18 years and above. A paper-based questionnaire was used, which comprised 16 questions related to the definition of food allergies, food allergens, and food allergy symptoms; the definition and prevention of cross-contact of food allergies; emergency treatment procedures for food allergies; strategies for the prevention of food allergy reactions; customer expectations towards restaurants; and preventive measures taken for food allergies. The results indicate that the overall average score of food allergen awareness was 10.90, which falls in the higher range. Furthermore, female students in the age groups of 23 to 27 years and 33 to 37 years had higher levels of awareness than female students in the age group of 18 to 22 years. The results also showed that the level of awareness among science college and health college students was statistically significantly higher (p < 0.05) than that among humanities college students. Post-graduate students also showed a higher level of awareness of food allergens than bachelor's students. These findings also indicate that listing all allergens in the restaurants and cafes' menus statistically significantly (p < 0.05) increased the level of awareness of female students about food allergens on restaurants' and cafes' menus, compared to restaurants and cafes that do not list all allergens on their menus. In general, female students at King Saud University showed a high level of awareness about food allergies on restaurants' and cafes' menus. The study recommends assessing the impact of awareness of female students with and without food allergies on their practices and behaviors.

Nutritional management of food allergies: Prevention and treatment

An individualized allergen avoidance plan is the cornerstone of the nutritional management of food allergy (FA). In pediatric age, the main objective is preventing the occurrence of acute and chronic symptoms by avoiding the offending food(s) and providing an adequate, nutritionally balanced and personalized diet at the same time. For this reason, the presence of a trained dietitian is recommended in order to meet nutritional needs of patients with FA and to provide a tailored nutritional plan, minimizing the impact of FA on quality of life and maintaining optimal growth.

Challenges of diet planning for children using artificial intelligence

BACKGROUND/OBJECTIVES

Diet planning in childcare centers is difficult because of the required knowledge of nutrition and development as well as the high design complexity associated with large numbers of food items. Artificial intelligence (AI) is expected to provide diet-planning solutions via automatic and effective application of professional knowledge, addressing the complexity of optimal diet design. This study presents the results of the evaluation of the utility of AI-generated diets for children and provides related implications.

MATERIALS/METHODS

We developed 2 AI solutions for children aged 3-5 yrs using a generative adversarial network (GAN) model and a reinforcement learning (RL) framework. After training these solutions to produce daily diet plans, experts evaluated the human- and AI-generated diets in 2 steps.

RESULTS

In the evaluation of adequacy of nutrition, where experts were provided only with nutrient information and no food names, the proportion of strong positive responses to RL-generated diets was higher than that of the human- and GAN-generated diets (P < 0.001). In contrast, in terms of diet composition, the experts' responses to human-designed diets were more positive when experts were provided with food name information (i.e., composition information).

CONCLUSIONS

To the best of our knowledge, this is the first study to demonstrate the development and evaluation of AI to support dietary planning for children. This study demonstrates the possibility of developing AI-assisted diet planning methods for children and highlights the importance of composition compliance in diet planning. Further integrative cooperation in the fields of nutrition, engineering, and medicine is needed to improve the suitability of our proposed AI solutions and benefit children's well-being by providing high-quality diet planning in terms of both compositional and nutritional criteria.

Nutrient intake in school-aged children with food allergies: a case-control study

Most studies assessed nutrient intake of young children with food allergy (FA) compared to healthy children. We aimed to compare macro- and micronutrient intake of school-aged children with FA to non-allergic children. This case-control study included 93 Italian children (52 with FA and 41 controls, median age 7.5 and 8.3 years, respectively). Macro- and micronutrient intake was assessed by a three-day food dietary record. Anthropometric measurements were also collected. The median height z-score was significantly lower in the FA group, despite a similar daily energy and protein intake. Calcium, iron and vitamin D intake was suboptimal in both groups, while protein intake was higher than recommended in both groups. Unexpectedly, children with FA consume more protein than controls, while having lower micronutrient intake, especially calcium. Our data suggest the importance of nutritional counseling for children with FA to ensure a balanced nutrient intake while on elimination diet.

Allergy education and training for physicians

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.

Diet and Food Allergy as Risk Factors for Asthma in the Arabian Gulf Region: Current Evidence and Future Research Needs

Asthma is a chronic respiratory disease which is associated with higher levels of systemic inflammation. The causes of asthma remain poorly understood. Unhealthy diet and food allergy are potential risk factors for developing asthma. The prevalence of asthma in the Arabian Gulf region (AGR), and Kuwait, Saudi Arabia and Qatar in particular, is higher than in other Eastern Mediterranean countries. In the AGR, diets tend to be of low nutritional value due to high levels of total energy, cholesterol, sodium, added sugars and saturated fat, and low levels of fiber, fruit and vegetables. A few studies that include children and adults in the AGR have suggested a potential link between unhealthy diets/specific food allergens and increased risk of asthma, however, the association of food allergy with asthma is still a controversial issue. The aim of this commentary is to consider the evidence from the AGR regarding the effects of diet/food allergy on asthma risk that may be used to make recommendations for future research.

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.

The Role of Nutritional Aspects in Food Allergy: Prevention and Management

The prevalence of food allergy in childhood appears to be increasing in both developed and transitional countries. The aim of this paper is to review and summarise key findings in the prevention and management of food allergy, focusing on the role of dietary components and nutritional habits in the development and optimal functioning of the immune system. Essential fatty acids, zinc and vitamin D are likely to enhance the anti-inflammatory and antioxidative barrier and promote immunologic tolerance. Additionally, nutritional components such as pre- and probiotics represent a novel research approach in the attempt to induce a tolerogenic immune environment. For all these reasons, the traditional avoidance diet has been, in recent years, completely reconsidered. New findings on the protective effect of an increased diversity of food introduced in the first year of life on allergic diseases are consistent with the hypothesis that exposure to a variety of food antigens during early life might play a role in the development of immune tolerance. Accordingly, therapeutic (and even preventive) interventions should be planned on an individual basis.

Tolerance and growth in children with cow's milk allergy fed a thickened extensively hydrolyzed casein-based formula

Background

In case of cow’s milk allergy (CMA), pediatric guidelines recommend for children the use of extensively hydrolyzed formulas (eHFs) as elimination diet. According to the American Academy of Pediatrics, the hypoallergenicity of each specific eHF should be tested in subjects with CMA.

Methods

A prospective, multicenter trial was performed to assess the tolerance/hypoallergenicity of a thickened casein-based eHF (eHCF, Allernova AR®, United Pharmaceuticals, France) in infants aged <12 months with CMA proven by a double-blind placebo-controlled food challenge. Its efficacy, measured through allergy symptoms monitoring and Cow’s Milk-related Symptom Score (CoMiSS) calculation, and safety were evaluated during a 4-month feeding period. Growth z-scores were computed based on WHO anthropometric data.

Results

Thirty infants (mean age: 4.8 ± 3.0 months) with CMA proven by a DBPCFC tolerated the eHCF during the 4-month study. The CoMiSS, crying and regurgitation scores significantly decreased by 4.2 ± 4.0, 0.9 ±1.2 and 0.7 ± 1.1 respectively, after 14 days of feeding (p < 0.001). The Scoring Atopic Dermatitis index, of 33.2 ± 14.8 at inclusion in 9 patients, significantly decreased by 15.5 ± 6.7 and 21.1 ± 11.2, after 14 and 45 days of feeding, respectively (p < 0.001). The percentage of infants having normal stool consistency (soft or formed stools) significantly improved from 66.7 % (20/30) at inclusion to 90.0 % (27/30) after 14 days of feeding (p = 0.020). The growth z-scores, negative at study inclusion, significantly improved over the 4-month study. No adverse event was related to the eHCF.

Conclusion

The thickened eHCF was tolerated by more than 90 % of included allergic infants with 95 % confidence interval and can therefore be considered as hypoallergenic in accordance with current guidelines. The improvement of growth indices and absence of related adverse events confirmed its safety. Results of this trial back the use of the tested thickened eHCF as an efficient and safe alternative in children with CMA.

Trial registration

ClinicalTrials.gov, number NCT02351531, registered on 27 January 2015

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0637-3) contains supplementary material, which is available to authorized users.

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.

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.

Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the Chicago experience

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated esophageal disease characterized by esophageal dysfunction and esophageal mucosal eosinophilia. Diet therapy is effective in the treatment of EoE in both children and adults. The role of food allergens is well established in the pathogenesis and treatment of eosinophilic esophagitis. Empiric elimination with a six-food elimination diet (avoiding milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) demonstrates remission in over 70% of adults with this disease. Dietary therapy in adult EoE is becoming more accepted by both patients and clinicians. Dietary therapy can be effectively implemented in clinical practice with appropriate dietary education, patient resources, and close communication with physician and clinical staff. The ability to identify specific food triggers to help tailor dietary therapy for long-term management allows for a return to consumption of most table foods. Furthermore, the diet approach avoids the need for chronic topical corticosteroid use and possible long-term side effects of these medications. The decision to proceed with dietary therapy should be decided by patient preference and available resources. A collaborative and multidisciplinary approach including gastroenterologists, allergists, nurses, and dietitians is essential in the success of this approach.

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.

Growth parameters impairment in patients with food allergies

Background and Aims. Food allergy (FA) is a common disease that is rapidly increasing in prevalence for reasons that remain unknown. Objective. The aim of this study was to analyze the clinical characteristics and anthropometric data of patients with food allergies followed in a tertiary centre of allergy and immunology. Methods. A retrospective study was performed that assessed the data records of patients with food allergy diagnosis, covering a period from February 2009 to February 2012. Results. 354 patients were evaluated in the period; 228 (69.1%) patients had a confirmed FA diagnosis. The z-scores for weight-for-age, height-for-age, and body mass indices-for-age showed lower significant values in the FA group compared with the non-FA group by Mann-Whitney test, with significance values of P = 0.0005, P = 0.0030, and P = 0.0066, respectively. There were no statistical differences in sex, gestational age, birth type, breastfeeding period, and age of introduction of complementary formulas based on cow milk protein between groups. Conclusion. FA patients had a lower growth rate in comparison with patients without FA. The early recognition of food allergies with the establishment of protein-implicated diet exclusion, in association with an adequate nutrient replenishment, is important to reduce the nutritional impact of food allergies.

Nutritional management and follow up of infants and children with food allergy: Italian Society of Pediatric Nutrition/Italian Society of Pediatric Allergy and Immunology Task Force Position Statement

Although the guidelines on the diagnosis and treatment of food allergy recognize the role of nutrition, there is few literature on the practical issues concerning the nutritional management of children with food allergies.

This Consensus Position Statement focuses on the nutritional management and follow-up of infants and children with food allergy.

It provides practical advices for the management of children on exclusion diet and it represents an evidence-based consensus on nutritional intervention and follow-up of infants and children with food allergy.

Children with food allergies have poor growth compared to non-affected subjects directly proportional to the quantity of foods excluded and the duration of the diet. Nutritional intervention, if properly planned and properly monitored, has proven to be an effective mean to substantiate a recovery in growth.

Nutritional intervention depends on the subject’s nutritional status at the time of the diagnosis.

The assessment of the nutritional status of children with food allergies should follow a diagnostic pathway that involves a series of successive steps, beginning from the collection of a detailed diet-history.

It is essential that children following an exclusion diet are followed up regularly.

The periodic re-evaluation of the child is needed to assess the nutritional needs, changing with the age, and the compliance to the diet.

The follow- up plan should be established on the basis of the age of the child and following the growth pattern.

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.

Fish and egg specific immunoglobin e in multiple sclerosis patients

BACKGROUND

The effect of nutrition in the course of multiple sclerosis (MS) is a topic of great interest. The present study was aimed to evaluate the immunoglobin E (IgE) against egg and fish in MS patients compared to healthy controls.

METHODS

Between March 2012 and July 2012, 48 MS patients were selected and compared with 48 healthy subjects to assess the frequency of IgE against egg and fish in MS patients compared to healthy control. Fish and Egg specific IgE was determined by Immuno CAP. Sex and the frequency of specific IgE were compared between study groups by Chi-square test.

RESULTS

Total of 96 subjects was assessed (22% male and 78% female). The mean age of the study subjects was 30.8 ± 6.6 years. Mean age of case and control groups was 30.7 (±6.9) versus 30.9 ± 6.3, respectively (P = 0.83). There were no detection of egg and fish specific IgE in serum of MS patients and healthy subjects.

CONCLUSIONS

IgE allergy against fish and egg may be very unlikely to affect MS course.