PAEDIATRIC
FOOD ALLERGIES IN TODDLERS: OVERCOMING THE CHALLENGES The prevalence of food allergy is increasing.1 Identifying the culprit food, obtaining a correct diagnosis and subsequent dietary management can be difficult. This is particularly the case in children under the age of five. The number of people being diagnosed with food allergy has increased dramatically over the past few decades. The cause for this increase (and allergy in general) is not yet fully understood, but is likely to be multifactorial. Food allergy now affects about 7% of children in the UK2 with food allergy being more common in children under the age of five, an age when consuming a balanced and varied diet to help achieve optimal growth and development is key. In light of the increase in prevalence, it has become more crucial for those who work in nutrition and/or paediatrics to recognise symptoms of atopy, to be able to conduct an allergy focused history and to provide the correct advice to parents and families on diagnosis and diet management.2,3 WHAT IS FOOD HYPERSENSITIVITY?
Some people develop symptoms when eating certain foods that cause no problems to most people. This is called food hypersensitivity, a term used to encompass all food-related reactions. Food hypersensitivity can be divided into food allergy and non-allergic food hypersensitivity, ie, lactose intolerance and hypersensitivity towards sulphites. It is well recognised that, with all food hypersensitivity, perception outweighs occurrence. This is due to
Rachel De Boer Principal Paediatric Allergy Dietitian and Member of the Infant & Toddler Forum (ITF)
the vast array of symptoms associated with hypersensitivity reactions, which can overlap with other conditions such as gastro-oesophageal reflux, toddler diarrhoea and constipation. WHAT IS FOOD ALLERGY?
Food allergy is a term to encompass food-related reactions that involve the immune system. There are two major types of food allergy: • IgE-mediated food allergies - these cause a rapid onset of symptoms, where the adverse effects usually appear within minutes following ingestion of the culprit food. The symptoms can range from mild to more severe reactions, which have the potential to be life-threatening. These reactions involve an antibody called IgE that circulates in the blood. Symptoms such as hives, rashes and swelling often manifest as a result of IgEmediated food allergies. However, the most serious reactions, known as anaphylaxis, can lead to respiratory distress and a severe drop in blood pressure and cardiac failure.
Rachel specialises in the diagnosis and management of paediatric food allergies. She works within a Children’s Allergy service in a large London teaching hospital and runs her own private practice. She is a committee member of the BDA’s Food Allergy and Intolerance Group and is on the Executive Committee of the KCL Allergy Academy.
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PAEDIATRIC Table 1: The 14 main foods that can cause an allergic reaction4 Celery
Molluscs
Cereals containing gluten
Mustard
Crustaceans
Tree nuts
Eggs
Peanuts
Fish
Sesame seeds
Lupin
Soya
Milk
Sulphur dioxide (sometimes known as sulphites)
• Non-IgE-mediated allergic reactions - these are sometimes termed ‘delayed onset’ food allergies. The symptoms associated with this type of reaction generally develop after at least two hours following ingestion of the culprit food and can take as long as 48 hours to develop. Non-IgE-mediated allergy can cause a broad spectrum of symptoms, including eczema, diarrhoea, vomiting and constipation. WHAT CAUSES FOOD ALLERGY?
The causes of food allergy are still poorly understood. Food allergies and allergic diseases in general, such as asthma, eczema and hay fever, share many risk factors. However, there appears to be a number of both genetic and nutritional factors that are specific to food allergies. For example, the timing of introduction into the diet and the amount consumed appear to be important factors, as is the amount of gastric acid in the stomach. It’s also known that composition of bacteria in an infant’s gut may influence susceptibility to food allergies. More research is needed into the causes of food allergies, with the aim of developing strategies to aid prevalence reduction. Which foods are most likely to cause food allergy? While any food can potentially cause a reaction, there are 14 foods that account for the majority of food allergic reaction (see Table 1) and, as such, their presence within any prepackaged foods sold within the EU must be clearly labelled. The foods most commonly associated with food allergy in toddlers are milk, egg and peanuts. Toddlers usually outgrow their allergic reactions to milk and to eggs often by the time they go to school, whereas peanut and tree nut allergies are more likely to persist.2,3
ACHIEVING A CORRECT DIAGNOSIS OF ALLERGIES
Diagnosis of allergies can be challenging; this is especially true in toddlers and young children, in part due to their inability to communicate and also because of symptoms overlapping with other medical conditions seen more commonly in toddlers. Diagnosing IgE-mediated food allergy is somewhat easier than non-IgE-mediated food allergy, due to the fact that the symptoms are usually rapid in their onset, making it easier to identify the culprit food after ingestion. There are two useful tests commonly used to aid diagnosis of IgE-mediated food allergies:3 • blood tests called specific IgE testing (spIgE) that measure the amount of specific IgE antibodies to a certain food circulating in the blood system; and • skin prick tests (SPE). However, prior to considering these tests, it is key that a detailed allergy-focused history is conducted.5 The only method to gain a clear diagnosis of non-IgE-mediated allergy is through an elimination diet followed by re-introduction of the food. Alternative testing (such as ‘Vega’ testing, etc) is not recommended. The scientific principles that they are based on are unproven and independent reviews have found them to be unreliable. Whilst all healthcare professionals working in paediatrics and/or nutrition should familiarise themselves with the correct advice for supporting parents, the diagnosis of food allergy should be made by a medical professional such as a doctor or dietitian. www.NHDmag.com March 2019 - Issue 142
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PAEDIATRIC MANAGING ALLERGIES IN TODDLERS
The optimum method in preventing allergic reactions is to identify the food that causes the allergy and avoid it. Hence the mainstay of treatment for food allergy in toddlers is through allergy avoidance. Following diagnosis of a food allergy, dietary advice should be provided by a dietitian who can advise on an appropriate dietary management plan.6 In addition to allergen avoidance advice, all toddlers with an IgE-mediated allergy should be given an allergy action plan that depicts which medications should be used in case of an accidental allergic reaction.3 Most commonly, antihistamines are recommended to treat allergic reactions in this age group; these work by blocking the effects of histamine, which is responsible for many of the symptoms of an allergic reaction. For those with more severe allergic reactions, an adrenaline auto injector (eg, EpiPen, Jext or Emerade) may be prescribed. Dietary advice The mainstay of treatment in food allergy is allergen avoidance via dietary advice. This may appear simple in theory, but can prove difficult in practice for parents and carers, and particularly for toddlers who have multiple food allergies. Advising parents on which food to avoid and offering suitable alternative foods, is key to help ensure that a toddler is meeting the nutritional requirements crucial for optimal growth and development during these early years of life.
It is important for dietitians and healthcare professionals working in food allergy to educate parents and carers by offering practical advice on which foods need to be avoided and to provide information on the suitable alternatives, how to adapt their usual recipes and to try out new ones. It is vital too, to offer advice on preventing food allergic reactions and cross-contamination when preparing meals for toddlers. It is important to support parents in becoming familiar with food labelling laws when buying prepacked foods and when eating out. European legislation dictates that all prepacked food for sale in the EU containing the allergen food groups and products thereof should be clearly labelled.4 Despite this, parents should always be advised to read the full ingredients list to be thorough in ensuring any meals or recipes do not contain the food that may cause the allergic reaction in their toddler. When advising families on allergen avoidance, it is also important to be clear on the level of restriction required. Whilst some toddlers will need to completely avoid an allergen, including possible traces, others will be able to include the allergen in certain forms, eg, many children with IgE-mediated milk and egg allergy can tolerate these foods in their baked form.7 Lastly, guiding parents through reintroduction of the allergen, either in a hospital setting for those with IgE-mediated allergy, or at home in those with non-IgE-mediated allergy, is an important part of the dietary management for any toddler diagnosed with food allergies.
THE ITF: WHAT WE DO The ITF promotes best practice in healthy habits from pregnancy to preschool through reliable clear evidence-based advice and simple practical resources aimed at practitioners, healthcare professionals and parents. @InfTodForum www.facebook.com/InfantandToddlerForum www.infantandtoddlerforum.org For more information and practical advice on food allergies and all things nutrition in children under the age of five, see ITF’s range of factsheets for healthcare professionals at: www.infantandtoddlerforum.org/health-childcare-professionals/factsheets For more information on face-to-face training for healthcare professionals, contact the forum on email at: info@infantandtoddlerforum.org ITF is supported by an unrestricted educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests.
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