Nutritional aspects and diets in food allergy.

Special Topics Ebisawa M, Ballmer-Weber BK, Vieths S, Wood RA (eds): Food Allergy: Molecular Basis and Clinical Practice. Chem Immunol Allergy. Basel, Karger, 2015, vol 101, pp 209–220 (DOI: 10.1159/000373904)

Nutritional Aspects and Diets in Food Allergy Anna Nowak-Węgrzyn · Marion Groetch Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, N.Y., USA

Dietary intervention is a crucial component of food allergy management but can negatively impact nutrient intake. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. Nutrition assessment may also be indicated in adults with food allergy. Frequently, an elimination diet is absolutely necessary to prevent potentially life-threatening anaphylaxis. Allergen elimination can also improve chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. Allergen elimination goals are to prevent acute and chronic food-allergic reactions in the safest and least restrictive environment to supply a balanced diet that promotes health in children and adults. © 2015 S. Karger AG, Basel

Food allergy management is focused on food allergen avoidance, which can have profound consequences on nutritional status. Recent food allergy guidelines recommend nutrition therapy or consultation with a dietitian [1, 2]. Dietary assessment and guidance are necessary for successful diagnosis and management of all types of foodallergic disorders [3]. Elimination of a food or

food group from the pediatric diet is associated with nutritional risk, so it is therefore important that elimination diets be prescribed only for the treatment of a diagnosed food allergy or for diagnostic purposes for a limited period of time. As many food allergies of early childhood resolve over time, regular reassessment by an allergist is also important to avoid extended, unnecessary elimination diets.

Elimination Diet in Food Allergy Diagnosis

A short-term elimination diet, e.g., 2–3 weeks for atopic dermatitis (AD) or 6–8 weeks for eosinophilic gastroenteropathies, can be used for diagnostic purposes [1]. Following symptom resolution, the food(s) may be slowly re-introduced to determine if symptoms recur. After more extended elimination, a physician-supervised oral food challenge should be performed since, in some instances, acute reactions may occur after a period of avoidance, even in patients who previously manifested only chronic eczema when food was in their diet on a regular basis [4]. In cases of gastrointestinal food allergy (e.g., eosinophilic Downloaded by: UCONN Storrs 137.99.31.134 - 5/25/2015 7:14:17 PM

Abstract

A 7-year-old boy with wheat allergy developed severe anaphylaxis with pharyngeal edema (stridor), cough, wheezing, generalized urticaria and emesis within 45 minutes of ingesting a small piece of cornbread that was baked at home from a store-bought mix. The inspection of the package revealed that the mix contained wheat flour as the second ingredient on the list. The boy’s father recalled reading labels on two cornbread mixes in the store: one that was wheat-free and one that contained wheat. He thought he had purchased the wheat-free cornbread mix. Key message: Label reading is challenging, and mistakes are common. Furthermore, the ingredients may change at any time, and constant vigilance is imperative. Reading product labels once at the point of purchase and then again prior to ingestion will help patients catch errors in label reading before a reaction occurs. Reprinted with permission from Groetch and NowakWęgrzyn [3].

esophagitis, allergic proctocolitis), food may be slowly reintroduced at home over the course of days or weeks, with the exception of food proteininduced enterocolitis syndrome, where supervised challenge is recommended [5].

Elimination Diet in Food Allergy Management

Following the confirmation of food allergy diagnosis by appropriate testing, the standard of care for food allergy management is strict avoidance of the offending food(s). Avoidance of food allergens is not simple and may have far-reaching nutritional consequences that impact the quality of life for the patient and the family. Mistakes in avoidance are common and may have grave consequences for individuals with the most severe phenotype of food allergy and who develop anaphylactic reactions from ingestion of trace

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amounts of foods [6] [see Box 1, Clinical vignette: pitfalls with label reading]. Avoidance of food allergens limits the selection of storebought food choices, imposes additional costs associated with purchasing specialty foods, and affects participation in social events, which typically revolve around food [7]. The commercial food industry is ever expanding, adding thousands of new food items each year. Additionally, ingredients in these commercial products can change frequently, so consumers must learn to read product labels each and every time an item is purchased [8]. Food allergen labelling laws begin by identifying foods that are considered the ‘common allergens’ or ‘major allergens’. These common allergens must be listed on the product label using the common name (e.g., milk, egg, wheat) rather than a scientific name (e.g., casein, albumin, starch). Additionally, major allergens may be hidden in a vague ingredient term such as ‘natural flavoring’. Laws that guide the labelling of food allergens vary from country to country, and each country or region identifies those foods that are considered common food allergens (see table 1). However, many countries do not yet have specific food allergen labelling laws; therefore, any allergen may remain hidden on product labels in these countries. Health care practitioners and patients should know their country’s food allergen labelling laws. Furthermore, when travelling abroad, patients with food allergies should familiarize themselves with labelling laws of their destination country prior to purchasing and consuming packaged foods [9].

Loopholes in the Labeling Laws

Food allergen labelling laws simplified the identification of allergenic ingredients but did not address the potential presence of allergens due to cross contact. The presence of allergenic ingredients due to cross contact confers a small but real risk of allergen exposure to consumers with food

Nowak-Węgrzyn · Groetch Ebisawa M, Ballmer-Weber BK, Vieths S, Wood RA (eds): Food Allergy: Molecular Basis and Clinical Practice. Chem Immunol Allergy. Basel, Karger, 2015, vol 101, pp 209–220 (DOI: 10.1159/000373904)

Downloaded by: UCONN Storrs 137.99.31.134 - 5/25/2015 7:14:17 PM

Box 1. Clinical vignette: pitfalls with label reading

Table 1. Major food allergens based on country-specific labeling laws Country or Countries

EU

USA, Mexico, Hong Kong, China

Australia and New Zealand

Canada

Japan

Korea

Identified allergens requiring full disclosure on product labels

Milk Egg Soy Gluten-containing grains Peanut Tree nuts Fish Shellfish-Crustacean and Mollusks Mustard Celery Lupine Sesame

Milk Egg Soy Wheat Peanut Tree nut Fish ShellfishCrustacean

Milk Egg Soy Wheat Peanut Tree nut Fish ShellfishCrustacean Sesame

Milk Egg Soy Wheat Peanut Tree nut Fish ShellfishCrustacean and Mollusks Sesame

Milk Egg Wheat Buckwheat Peanut Shrimp Crab

Milk Egg Wheat Buckwheat Soy Peanut Mackerel Crab Shrimp Pork Peach Tomato

Table 1 lists the foods that are considered allergens, by country. Ingredients derived from the listed foods require full disclosure on product labels. Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

either avoid the product or call the manufacturer to determine if their specific allergen is an ingredient in the product.

Changing Paradigms in the Management of Milk and Egg Allergy: Baked Milk and Egg Diet

As many as 70% of children with milk or egg allergy tolerate extensively heated milk or egg ingredients in baked goods [11, 12]. Extensive heating of milk and egg ingredients decreases protein allergenicity by destroying conformational epitopes and enhancing gastrointestinal digestion [13, 14]. The consumption of extensively heated milk and egg protein in the diet of children with milk or egg allergy who can tolerate the baked form appears to accelerate the resolution of milk and egg allergy [15, 16]. Children who incorporated baked milk into the diet were 16 times more likely to become tolerant to un-

Nutritional Aspects and Diets in Food Allergy Ebisawa M, Ballmer-Weber BK, Vieths S, Wood RA (eds): Food Allergy: Molecular Basis and Clinical Practice. Chem Immunol Allergy. Basel, Karger, 2015, vol 101, pp 209–220 (DOI: 10.1159/000373904)

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allergies. Manufacturers may address this risk with a precautionary label such as ‘may contain milk’ or ‘manufactured in a facility that manufactures milk products’, but these labels are not mandatory, and they are unregulated, leaving consumers feeling unsure about the safety of manufactured products [10]. The National Institute of Allergy and Infectious Diseases food allergy guidelines suggest that consumers avoid products with precautionary labels for their allergens [1]. The labelling laws only apply to foods considered major allergens. While the vast majority of allergic reactions occur to 8 foods – milk, egg, wheat, soy, peanut, tree nut, fish, shellfish – consumers who are allergic to other ingredients may have a more difficult time interpreting product labels. For those allergic to an ingredient not considered a major allergen, additional precautions are necessary. These ingredients may be denoted by a vague labelling term such as ‘natural flavoring’ or ‘spice’. These vague ingredient terms will alert the consumer with allergies that they should

A 5-year old child with milk allergy passed an oral food challenge, under physician supervision, to a muffin baked with 1.3 g of milk protein. She added baked milk products to her diet and reported several episodes of itchy mouth and abdominal pain with baked products such as cakes and breads. The inspection of the baked products revealed that they were not baked through and were too moist and soggy in the middle. After thorough baking was enforced, the child had no subsequent complaints. Key message: Under-baking may result in allergic symptoms. Reprinted with permission from Groetch and NowakWęgrzyn [3].

baked milk compared to a group of children who continued strict avoidance of milk ingredients [15]. Children who incorporated baked egg into the diet were 14.6 times more likely to develop regular egg tolerance than children in the comparison group (p < 0.0001), and they developed tolerance earlier (median 50.0 vs. 78.7 months; p < 0.0001) [16]. In patient populations at large, the adherence to the principles of the baked milk/egg diet may be less stringent than that in clinical trials [see Box 2, Clinical vignette: baked milk diet]. Monitoring is necessary; physicians, dietitians, and nurses must understand how to provide guidance on incorporating baked foods with milk and eggs. For instance, it is not always obvious from a product label how an ingredient was processed [17]. For example, a frosted cookie or cake may contain baked milk in the cake and unbaked milk in the frosting, or a flavored cracker may have a baked milk ingredient or it may have a milk ingredient in the flavoring that is topically applied after the cracker is baked. So, while introducing baked milk or baked egg ingredients into the diet may greatly improve the quality and diversity of the diet, it also introduc-

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es additional nuances to avoidance that must be conveyed to the consumer with allergies. In such situations, dietary education is necessary. Table 2 provides examples of foods tolerated by patients who pass a baked milk or baked egg challenge. A physician may choose to advise the family to add additional baked milk or egg items or may even limit some of these items or the serving sizes of these items based on the patient’s clinical history [17].

The Effects of Allergen Avoidance on Nutrition in Children

Children with food allergies are at nutritional risk because they are likely to avoid foods of important nutritional value, such as cow’s milk, and their nutritional needs for growth and development are substantial. The younger the child and the greater the number of food allergens avoided, the higher the risk of nutritional deficiencies. An avoidance diet must fulfill the nutrient needs of an individual child within the context of the allergen-restricted diet. Therefore, comprehensive dietary education entails the avoidance of specific allergens and guidance on how to properly substitute for the nutrients provided by the avoided food(s). Children with food allergy on elimination diets are at risk for poor energy intake [18, 19], and children with food allergies tend to be smaller than children without food allergies, even when nutrient intake is similar. Suppressed growth may result from higher protein and energy requirements in children with moderate to severe AD, which is common in many children with food allergies [20]. Children with cow’s milk protein allergy and AD had lower albumin levels than healthy controls, despite similar protein intake [21]. Loss of nutrients may occur through abnormal intestinal permeability and absorption caused by poor adherence to the avoidance diet, additional undiagnosed food allergen, residual



Box 2. Clinical vignette: baked-milk diet

Table 2. Guidelines for incorporating baked milk and baked egg in the diet Types of foods

Allowed

Not allowed

Baked milk diet

– Store-bought baked goods such as rolls, muffins, cupcakes, cookies, crackers and bread, with milk or milk protein ingredients listed as the third ingredient or further down the list of ingredients. – Home-baked goods (such as rolls, muffins, cupcakes or cookies) that have 240 ml of milk per batch of a recipe (yield of 6 servings per batch or approximately 40 ml of baked milk per serving). – Home-baked items with center that is thoroughly cooked through (not moist or soft). Products should be baked in individual serving size: cupcakes, not cakes; brownie muffins, not brownies; rolls, not bread. – Baked milk containing baked goods with milk-free chocolate chips. – Remember to check store-bought products and ingredients based on the patient’s other food allergies in order to avoid a reaction to other allergens. – Servings are specified in the nutritional information section of the food label or determined by the yield of the recipe.

– Store-bought baked goods such as rolls, muffins, cupcakes, cookies, crackers and bread, with milk or milk protein ingredients listed as the first or second ingredient. – Home-baked goods with more than 40 ml of baked milk per serving. – Full-sized, home-baked products such as cakes, brownies and breads (commercial breads are safe) that may not be fully cooked in the middle. – Baked milk-containing baked goods with milk chocolate chips. – Continue to avoid milk products that are not fully baked, such as milk-based frostings, icings, and milk-containing flavorings that are topically applied after the product is baked.

Baked egg diet

– Store-bought baked products with egg listed as the third ingredient or further down the list of ingredients. – Home-baked products that have no more than 2 eggs per batch of a recipe (yield of 6 servings) or 1/3 of a large egg. – Home-baked items with center that is thoroughly cooked through (not moist or soft). Products should be baked in individual serving size: cupcakes, not cakes; brownie muffins, not brownies; rolls, not bread. – Remember to check store-bought products and ingredients based on your child’s food allergies in order to avoid a reaction to other allergens.

– Store-bought baked products with egg listed as the first or second ingredient. – Home-baked products that have more than 2 eggs per batch of a recipe (yield of 6 servings) or 1/3 of a large egg. – Full-sized, home-baked products such as cakes, brownies and breads (commercial breads are safe) that may not be fully cooked in the middle. – Continue to avoid: Caesar salad dressing; custard; eggs in the form of hard boiled, scrambled or poached, etc.; French toast; frosting; ice cream; mayonnaise; quiche.

Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

Cow’s Milk Allergy Cow’s milk and cow’s milk products are major sources of calcium, riboflavin, phosphorus, pantothenic acid, vitamin B12 and vitamin D (in countries with vitamin D-fortified milk), protein and fat. Avoidance of cow’s milk compared to


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reactivity to the substitute formula, or intrinsic factors that predispose the individual to food allergy [21]. Optimal nutrition is of paramount importance because suboptimal nutrient intake may exacerbate the risk of lower growth rates in children with food allergies.

Table 3. Alternative sources for nutrients in cow’s milk Nutrient

Alternative dietary sources

Calcium

Fortified alternative beverages (soy, rice, oat, almond, coconut, hemp, potato), calcium-fortified tofu, calcium-fortified juice

Vitamin D*

Fortified alternative beverages, fortified margarine, fortified alternative yogurts, fish oils, salmon and other fatty fish

Vitamin B12

Meat, fish, poultry, eggs, enriched alternative ‘milk’ beverages

Vitamin A

Liver, egg yolk, fortified margarine, dark green leafy vegetables, deep orange fruits and vegetables, fortified alternative beverages

Pantothenic acid

Meat, vegetables, eggs, whole grains, legumes, fish

Riboflavin

Dark green leafy vegetables, enriched and whole grain products

Protein

Meat, fish, poultry, eggs, soy products, peanut, other legumes, tree nuts and seeds

Fat

Vegetable oils, margarine, avocado, meats, fish, poultry, peanut, tree nuts, seeds

* In countries where milk is fortified, read labels of alternative ‘milk’ products for degree of fortification. Fortified alternative beverages are not appropriate for infants and may not be safe and appropriate as a substitute for fluid milk for toddlers and young children. Please consider the overall nutrient intake and potential risks. Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

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sential micro- and macronutrients is recommended. In a population-based survey, children (age 31–37 months old) on milk-free diets had significantly lower intakes of energy, fat, protein, calcium, riboflavin and niacin [18]. When a milk substitute (either a soy formula or hydrolyzed formula) was included in the diet, the nutritional content improved significantly, although calcium and riboflavin intakes remained below the recommended levels. Micronutrient supplementation may be necessary to meet nutrient needs in this population. Enriched alternative beverages are often used as milk substitutes for toddlers and older children. If tolerated, an enriched soy beverage can be a good substitute because it contains appropriate amounts of protein and adequate fats [3]. Other plant-based beverages such as rice, almond and potato ‘milk’ are very low in protein and fat and are not appropriate as a primary substitute for cow milk. In addition, an enriched rice



avoidance of other food allergens is more likely to result in inadequate nutrient intake and decreased growth [18, 19] (see table 3). Exclusive breastfeeding is recommended for infants up to 4–6 months of age, at which time the gradual introduction of complementary solid foods should begin. Some infants with cow’s milk allergy may require elimination of cow’s milk from the maternal diet due to allergic symptoms. In this case, the maternal diet should be evaluated for adequate nutrient intact, most specifically calcium and vitamin D, and supplementing the maternal diet might be necessary. The World Allergy Organization’s Diagnosis and Rationale for Action against Cow’s Milk Allergy guidelines recommend continuing either breastfeeding (with maternal milk avoidance) or a substitute formula for all infants and toddlers up to 2 years of age with milk allergy [2] (see table 4). After 2 years of age, a dietary assessment and guidance to ensure adequate intake of all es-

Table 4. Substitute formula recommendations for infants and toddlers with cow’s milk allergy, as per the Diagnosis and Rationale for Action against Cow’s Milk Allergy guidelines* Food allergy disorder

First formula recommendation

Second formula recommendation

Third formula recommendation

Low risk of anaphylaxis High risk of anaphylaxis Non-IgE (FPIES or Proctocolitis) Eosinophilic esophagitis

eHF-C AAF eHF-C AAF

AAF eHF-C AAF –

Soy Soy – –

* Diagnosis and Rationale for Action against Cow’s Milk Allergy guidelines should be interpreted with consideration for patient preference, individual clinical circumstance and cost. FPIES = Food protein-induced enterocolitis syndrome; eHF-C = Hypoallergenic, extensively hydrolysed casein-based formula; AAF = Hypoallergenic amino acid-based formula; Soy = Soy-based formula. Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

and seeds, which are additional sources of protein in the diet. Protein intake in children should comprise 10–30% of the daily energy intake (5–20% in infants). In addition to an appropriate milk substitute, protein intake can be improved by incorporating a variety of small amounts of proteinrich foods in each meal and snack. Grains Whole and enriched grains are excellent sources of complex carbohydrates, vitamins (thiamin, niacin, riboflavin, vitamin B6), dietary fiber, iron and magnesium. In some countries, grains are also enriched with folic acid. Wheat is the most common grain allergy, with major allergens contained in the gluten fraction. Gluten is also found in rye, barley, spelt and their hybridized varieties. When wheat is eliminated, nutrient-dense alternative grains should be provided to substitute for the nutrients normally provided by wheat in the diet (see table 5 for suggestions). Gluten-free products are also wheat-free and may be useful on a wheat elimination diet when other wheat-free grains are tolerated. These products are more expensive, however, and may not be universally available, so the wheat-allergic population may benefit from advice and re-


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beverage, when consumed in quantities similar to the average consumption of cow’s milk (approximately 280 ml), presents the additional concern of increased exposure to daily dietary inorganic arsenic. The European Food Standards Agency advises against the substitution of breast milk, infant formula or cow’s milk by rice beverages for toddlers and young children (up to 4.5 years of age) based on the poor nutritional quality and the concern for increased exposure to inorganic arsenic. Young toddlers require 30–40% of their daily energy intake from fat. However, children on milk avoidance diets must eliminate common sources of fat such as full-fat yogurts, butter and cheeses as well as many manufactured and processed foods that contain milk as an ingredient. If dietary fats are not intentionally added, the resulting diet may be too low in fat, essential fatty acids and energy. Adding sufficient oil (e.g., milkfree margarine or vegetable oils such as olive, canola, soy, corn, safflower) to meet fat, essential fatty acid and energy needs is a practical suggestion. Adequate protein is another area of concern for individuals on a pediatric milk elimination diet. Young toddlers may be unable to eat or may not accept meat, fish, poultry, eggs, nuts, legumes

Table 5. Alternative sources for nutrients in wheat Nutrient

Alternative dietary sources

Niacin

Meat, poultry, tuna, salmon, liver, peanuts, seeds, legumes, enriched and whole grain alternative grain products

Thiamin

Liver, pork, other meats, sunflower seeds, enriched and whole grain alternative grain products, nuts and legumes

Riboflavin

Milk, dark green leafy vegetables, enriched and whole grain alternative grain products

Iron

Heme iron: Meat, fish, shellfish, poultry Non-heme irons*: Enriched and whole grain alternative grain products, legumes and dried fruits

Folic acid

Enriched and whole grain alternative grain products**, beef liver, spinach, legumes (especially lentils), avocado, orange juice

Carbohydrates

Fruits, vegetables, legumes and products made with alternative grains or flours such as rice, oat, corn, buckwheat, potato, tapioca, amaranth, millet, quinoa

Fiber

Fruits, vegetables, alternative whole grains

* Non-heme iron sources are better absorbed if consumed with a food that provides vitamin C. ** Product labels must be read, as policies regarding enrichment vary based on country of origin. Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

Soy, Egg, Peanut, Tree Nut, Fish and Shellfish Allergies Although these common food allergens in children are all nutrient-dense, they typically do not supply a large percentage of daily energy intakes. If the diet is diverse, the nutrients in these foods can easily be provided by other foods in the diet. Additional dietary constraints, such as a vegetarian diet, a picky or faddy eater or a diet restricted for religious reasons may make meeting nutritional needs more challenging. Avoidance of peanut and tree nuts is more challenging due to the ubiquitous presence of these foods in candy, chocolates and baked goods as well as the high allergenic potential for inducing severe reactions upon exposure to trace amounts of the foods.

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Nutritional Impact of Specific Food-Allergic Disorders

In addition to the type of food that is avoided, the type of food-allergic disorder may influence the potential for nutritional risk. Table 6 highlights nutritional issues in AD, eosinophilic esophagitis, food protein-induced enterocolitis syndrome and allergic proctocolitis.

Feeding and Developmental Needs

Infants with food allergies have the same developmental needs associated with eating as all other infants. A healthy baby is born with the ability to coordinate sucking, breathing and swallowing and so can instinctively nurse or take a bottle. Other feeding skills are learned, and infants master foods of varying flavors and textures through practice. Thus, the gradual



sources for on-line ordering or education regarding how to prepare wheat or gluten-free meals and snacks from ‘scratch,’ which would be less expensive.

Disorder

Food allergy relevance

Nutritional risks

Management

Atopic dermatitis (AD)

About 35% of children with moderate-severe persistent AD have symptoms upon food ingestion. Elimination of the offending food can improve the AD symptoms.

Due to the chronic waxing/waning nature of AD, multiple foods may be unnecessarily eliminated by caregivers.

National Institute of Allergy and Infectious Diseases guidelines support the removal of suspected foods to identify potential triggers, followed by physician-supervised oral food challenge. Following a period of food avoidance (as soon as 2 weeks), acute symptoms may be elicited by foods that previously caused chronic eczema.

Eosinophilic esophagitis (EoE)

A subset of children and adults with EoE has food allergies.

Chronic emesis, abdominal pain, poor appetite, food refusal or other maladaptive feeding behaviors.

Whether and which foods are implicated in EoE are determined by documenting the resolution of EoE with specific food removal followed by a recurrence of disease when the specific food is reintroduced. As such, dietary management of EoE requires an elimination diet to determine trigger foods.

Food protein- Typically begins in early induced infancy in response to milk proctocolitis or soy proteins either in the breast milk or infant formula.

Blood and mucous in the stool and possibly diarrhea appear benign without an accompanying growth delay or overt nutritional risk. These symptoms typically resolve within 48–72 hours after removal of the suspected antigen.

Nutritional risk is minimal because tolerance is typically acquired by 1 year of age and nutritional substitution in infancy is easily achieved. Infants can continue breastfeeding with maternal dietary elimination of the trigger food(s) or can be fed a hypoallergenic formula with maternal elimination of cow’s milk. The maternal diet should be evaluated, and a safe alternative milk substitute or supplementation of calcium and vitamin D in the maternal diet may be required.

Food proteininduced enterocolitis syndrome (FPIES)

FPIES usually begins prior to 6 months of age and is resolved by 3 years of age; children may be affected throughout the toddler years or longer. Children with FPIES exhibit gastrointestinal symptoms that include delayed, recurrent vomiting (100%) and diarrhea (25%). In infants with reactions to multiple foods, feeding refusal and difficulties are common.

FPIES differs from proctocolitis and IgE-mediated allergies in that the breastfed infant can typically continue nursing without maternal dietary avoidance of the allergen. Only rare cases of FPIES in exclusively breastfed infants have been reported. Infants with milk or soy FPIES have a greater chance of developing solid food FPIES, most commonly to rice and other grains. Introduction of fruits and vegetables is often recommended prior to grains, and these fruits and vegetables may not provide the iron and zinc needed in this age group (30). If supplemental substitute formulas are not in the diet, micronutrient supplementation may be required until the diet has greater diversity. In infants with reactions to multiple foods, feeding difficulties are common.

FPIES is often associated with milk proteins in infant formulas, with a potential risk of concomitant soy protein allergy reported in the U.S. FPIES to solid food proteins may also occur and has been reported most commonly in response to grains such as rice, oats, barley but also to chicken, turkey, egg white, green pea, peanut, sweet potato, white potato, fruit protein, fish, and mollusks (in adults).


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Table 6. Nutritional issues of selected food allergy disorders

Box 3. Clinical vignette: feeding refusal A 10-month-old infant had been breast-fed since birth without any formula or micronutrient supplementation. At the age of 5 months, he had two episodes of repetitive, forceful emesis within 2 hours following ingestion of rice cereal that was treated with intravenous rehydration in the emergency department. He had milder emesis episodes followed by diarrhea with the ingestion of oatmeal and sweet potato. He was given a presumptive diagnosis of food protein-induced enterocolitis syndrome and was referred for diagnostic oral food challenges. Following a negative skin prick test, his parents were advised to gradually add apples and butternut squash to his diet at home. His mother was reluctant to try these foods at home, so an office oral food challenge was done. During the challenge, he consistently refused the foods, pushing away the spoon and spitting up the contents. He also refused additional solids such as banana and pear. He was referred to a feeding specialist for evaluation, and elemental semi-solid food was recommended as an alternative to improve feeding skills and to provide an additional source of energy and micronutrients, specifically zinc. A multivitamin supplement was added to meet his vitamin D and iron needs. Key message: Young, breast-fed infants with a history of reactions to solid foods and delayed introduction of solid foods to their diet may develop feeding difficulties. The food refusal may be related to past unpleasant experiences with solid food, and the problem can be compounded by parental apprehension about trying new foods because of past traumatic experiences. Counseling parents about strategies for enhancing feeding and oral skills is critical in these infants. Reprinted with permission from Groetch and Nowak-Węgrzyn [3].

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ple textures. It can be mixed with breast milk (or a safe substitute formula) into a smooth, thin or thick puree, mashed so that it is lumpy, or soft cooked and chopped so it provides an appropriate finger food texture.

Nutritional Issues in Adults with Food Allergy

Although we are more often concerned about the nutritional needs of children with food allergies, adults with food allergies would benefit from nutritional guidance as well. The most common allergens of adult IgE-mediated food allergy are peanut, tree nuts, fish, shellfish, fruits and vegetables [23]. Although peanuts, tree nuts and seafood contain concentrated nutrients, they can be omitted without nutritional consequence from an otherwise healthy diet. Systemic allergy to multiple fruits and vegetables is uncommon; it is more common for adults with hay fever to have pollen food allergy syndrome (PFAS), resulting in oropharyngeal symptoms to



presentation of foods of various flavors and appropriate textures is required. It is best if feeding opportunities can be presented when developmentally appropriate, and there appear to be critical periods in infant development when chewing and taste acceptance are more easily learned. For instance, when textured foods are introduced after 10 months of age, children are more likely to refuse solid foods [22] [see Box 3, Clinical vignette: feeding refusal]. If necessary, a commercial, semi-solid, hypoallergenic food may be provided. Feeding age-appropriate textures is more challenging for a child with food allergies due to food avoidance, and families will benefit from specific guidance regarding food introduction. An infant with milk or soy allergy may be introduced to a variety of flavors and textures through grains, fruits, vegetables, and meats in a skill-appropriate manner. Even an infant with a very limited diet can be provided a variety of textures with safe ingredients with a little creativity. For instance, a diet of only butternut squash can provide multi-

specific raw plant proteins. PFAS occurs in about 5–50% of patients with pollen allergies and is caused by structural homologies between raw plant proteins and pollen allergens. As these proteins are heat-labile and easily denatured upon exposure to initial digestion, symptoms are most commonly limited to the mouth and pharynx. Therefore, cooked versions of the fruits and vegetables are typically well tolerated, so it is not necessary to eliminate all raw fruits and vegetables. Of course, primary allergy to fruits and vegetables may also occur. Fruits and vegetables are important sources of beta-carotene, fiber, and phytonutrients and are the sole sources of vitamin C in the diet. There is one reported case of scurvy caused by vitamin C deficiency in an adult male patient who removed all fruits and vegetables due to PFAS [24]. Wheat allergy, although less common in adults, may manifest as food-dependent, exercise-induced anaphylaxis in adults [25, 26]. Avoidance of wheat will present the same nutritional consequences in adults, so instructions on when wheat should be avoided and when it can be safely included can be helpful. Safe alternative grain options should be discussed. Milk avoidance in adults may result in calcium deficiency, so ensuring an appropriate calciumfortified milk substitute or calcium supplementation is essential.

Adults are also not immune to poor dietary intake, picky eating or fad diets that limit nutrient intake or even specific foods such as wheat or casein in the belief that these foods are harmful. The nutritional content of any one diet is multifactorial, so an assessment is warranted to ensure that any elimination diet continues to provide adequate nutrition.

Summary

Dietary intervention is a crucial component of food allergy management but can negatively impact nutrient intake. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. Nutrition assessment may also be indicated in foodallergic adults. Frequently, an elimination diet is absolutely necessary to prevent potentially lifethreatening anaphylaxis, and allergen elimination can improve chronic symptoms, such as AD, when a food is proven to trigger symptoms. Allergen elimination goals are to prevent acute and chronic food-allergic reactions in the safest and least restrictive environment to supply a balanced diet that promotes health in children and adults.

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Assoc. Prof. Anna Nowak-Węgrzyn, MD Jaffe Food Allergy Institute Icahn School of Medicine at Mount Sinai One Gustave L. Levy Place, Box 1198 New York, NY 10029 (USA) E-Mail [email protected]

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

Food intolerance and allergy: increased incidence or contemporary inadequate diets?

Growth and nutrition in children with food allergy requiring amino acid-based nutritional formulas.

Food allergy.

Food allergy.

Food allergy.

Anaphylaxis in food allergy.

Year in review: pediatric allergy and asthma, excluding food allergy.

Atopic eczema and food allergy.

Food additives, allergy and hyperkinesis.

Rheumatoid arthritis, food, and allergy.

EAACI food allergy and anaphylaxis guidelines: managing patients with food allergy in the community.

Early exposure to food and food allergy in children.

Lethal food allergy in children.

GALT involvement in food allergy.

Diagnosis of Food Allergy.

Food allergy: a commentary.

Nonvalidated food allergy tests.

Immune mechanisms in food allergy.

Nutritional aspects of AIDS.

History of food allergy.

EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy.

Food allergy in adolescence and adulthood.

Food Allergy and Intolerance in IBS.