This issue was sponsored by Abbott Laboratories S.A (PTY) LTD All Abbott products are lactose and gluten free Tel: +27 (0)11 8582054

 

Contents A. Case study B. More information C. Editors' comments D. References E. CEU questions

Index

A. Case study
A 13-month-old boy was brought to the clinic with symptoms of eczema and asthma. He had presented with alternating diarrhoea and constipation from about 4 months and had been treated when necessary. His mother was extremely anxious, as he had been diagnosed a month prior with an egg and milk allergy by means of a skin prick test. Since the diagnosis, she had attempted to eliminate from his diet all wheat, egg, milk, peanuts, soya and fish, as she had heard from a friend that it would be best to avoid all potential allergenic proteins, and she was concerned that he would develop severe clinical symptoms. The skin prick tests to peanuts, soya and fish had in fact been negative, ruling out IgE-mediated reactions to these foods.

Anthropometric measurements revealed that he was not stunted but mildly wasted. His dietary intake was limited to sweet potatoes, rice, chicken, butternut and pears. He tended to eat only smooth textures and was still breastfed 3 times a day. His mother had breastfed him since birth but had introduced soya formula feeds at 4 months. She had noticed his eczema from about 1 month of age, and it had worsened progressively during his first year of life. She had been using cortisone cream on him at night, hoping that he would sleep through the night. Complementary foods were introduced at 4½ months and tended to be maize and rice cereal and yoghurt. The gastrointestinal symptoms had started at about this time. She had never linked his symptoms to her breastmilk or the food that he ate and had not avoided any potential allergens. The boy had developed asthmatic symptoms at 11 months of age; hence her visit to the allergy clinic a month before.

At the allergy clinic, she was referred to a dietitian, who felt education was essential at this stage. In collaboration with the allergist, the dietitian provided consistent information regarding the disease and the treatment thereof. An elimination diet was implemented, providing appropriate guidelines for a milk- and egg-free diet. The mother was given practical advice with guidelines for label reading, recipes, and coping mechanisms for going out recreationally and dealing with family occasions. She was advised to vary tastes and textures within his allowed food choices. The dietitian also suggested that breastfeeding be stopped and that soya milk feeds be given as a substitute for cow’s milk.

On follow-up, there was some improvement in the eczema, but the child was still experiencing gastrointestinal symptoms. He had lost weight, moreover. On questioning, it was found that his mother was still restricting his diet in terms of variety and texture and was still eliminating wheat, fish and peanuts. She said he was a picky eater and was not eating what she offered him. She had also taken her son out of the play group which he had been attending 3 mornings a week. He was listless, and she had noticed that he was far less active, walking and crawling less. He was even struggling to pull himself up with support.

WHAT CAN BE DONE AT THIS STAGE?
a. Assess adherence to the milk- and egg-free diet as well as the intake of possible hidden allergens.
b. Evaluate the nutritional adequacy of the diet.
c. Are there any additional allergens that the child may be reacting to, including environmental allergens?
d. Evaluate the need for additional therapy, such as physiotherapy, occupational therapy, sensory therapy, or speech therapy.

The mother was interviewed to investigate the above.
a. The mother revealed that she had still been offering her son the odd chocolate and milkshake, as she felt guilty that he was not allowed “fun foods”. She was concerned that he was being handled differently than other children. She was still breastfeeding, without having eliminated the allergens from her own diet.
b. The child was still eating an extremely restrictive diet, with almost no variety added after the initial visit. The diet was deficient in protein, overall calories, vitamins and minerals. Foods were still only smooth in texture.
c. The child was still drinking soya milk, a potential allergen that had not yet been eliminated, so a potential non-IgE-mediated allergy needed to be ruled out. Regarding environmental allergens, there were no carpets or pets at home, and he was seldom allowed out of the house since being removed from the play group. He wore only cotton clothing, and the washing powder was the brand suggested by the allergy clinic.
d. Interrogation of the child’s development and evaluation of clinical symptoms suggested referral to specialist clinics for more detailed assessment.

WHAT COULD BE DONE AT THIS POINT?
a. Remove all milk and egg sources from the diet.
b. Reevaluate in 2 weeks and consider a blinded food challenge with soy formula if the diet has been adhered to but symptoms persist.
c. Refer to specialists for developmental assessment.

a. The dietitian reaffirmed the need to eliminate egg and milk products completely, including milkshakes and chocolates. She provided recipes and appropriate milk- and egg-free alternatives for desserts and treats. The mother was not prepared to remove egg or milk from her own diet, so she was advised again to stop breastfeeding. It was felt not only that was it exposing the child to allergens but that it might also be compromising his appetite for nutrient-dense foods.
b. After 2 weeks, there was some improvement in the severity of the eczema, but he was still experiencing diarrhea and gastrointestinal discomfort. Though the diet was unnecessarily restrictive, at least egg and milk were now completely avoided. It was suggested that a food challenge be carried out at the clinic to investigate a possible reaction to the soya milk. The mother agreed, and a single blind food challenge was performed. Three hours after ingestion of approximately 175 ml soya milk, he started itching and developed loose stools. A diagnosis of a non-IgE mediated soya allergy was made, and advice was given regarding appropriate milk alternatives. The boy refused to drink an extensively hydrolysed formula. After trying the various options, he took rice milk. A calcium and vitamin supplement was prescribed. His symptoms improved dramatically.
c. Referrals were made to a pediatric physiotherapist to assess the child’s physical development; to a speech therapist, to assess any oral hypersensitivity or oral and texture aversions and to an occupational therapist to assess tactile defensiveness and to help with play and socializing skills.

Guidelines were reemphasized with special attention being given to ensuring that her son be treated no differently and be allowed to attend the crèche, parties etc.

The family missed their next follow-up and 4 months later, the boy was admitted with hypoalbuminaemia and clinical symptoms of kwashiorkor. His eczema had improved and the gastrointestinal symptoms had resolved.

WHAT COULD THE CAUSE BE?
a. A nutritionally inadequate and over restrictive diet?
b. Another underlying primary or secondary medical condition

a. Thorough evaluation of his elimination diet revealed that mom had now stopped breastfeeding and was avoiding the soya, egg and milk products perfectly. She was unfortunately also excluding all protein, wheat products, tropical and citrus fruit, tomatoes and green vegetables as she had read on the internet that these could be highly allergenic foods.
b. Interrogation and clinical assessment suggested further investigation of point (a.) was required before assessment for other potential underlying medical conditions.

It was explained to the mother that she need not avoid the other foods and that she was being overprotective of her son. She refused to accept the advice and said she was too scared to include these foods as her child’s symptoms had almost completely cleared. Even though it was explained that this dietary regime was the reason for his compromised nutritional status, she would not budge.

WHAT CAN BE DONE?
a. Provide evidence to convince the mother that the child was not allergic to those foods. This may be performed by skin prick testing or serum-specific IgE testing to prove to the mother that the child was not allergic to those foods, or food challenges for the spectrum of foods being eliminated for more objective confirmation
b. Allied health professional intervention
c. Psychological consultation for the parents (and older siblings?)

a. Mom was extremely anxious at the prospect of more tests and needles so it was decided to do double-blind placebo-controlled food challenges because it would allow the parents and family to experience a procedure that is closer to their daily experiences than a skin or blood test. It also would help parents and patients better tolerate any changes in their diagnosis and behaviour.
The boy was admitted to hospital to ensure a controlled environment would be maintained and a series of double blind placebo controlled food challenges were carried out over a 2 week period to establish the presence or absence of a clinical food allergy. A nutritionally balanced ‘hypoallergenic diet’ was prescribed.
b. Intensive occupational and speech therapy were initiated during the 2 weeks in hospital.
c. A psychologist counseled the parents on issues surrounding the care of an allergic child within the family setting and their dynamics.

After the period of hospitalization, food challenges confirmed allergy to only egg, milk and soya. The parents were satisfied and started implementing all the necessary dietary changes as suggested by the dietitian. They started socializing with family and friends again and sent their son back to morning crèche, after educating the staff about his allergies and emergency management. A month later, he had dramatically improved and the family situation was calm and more balanced. He had also started eating more variety within his allowed food choices.

TIP for Allergy Advisor users: Allergy Advisor contains many patient information sheets that can assists patients with their difficult life with an allergy. The following are some examples: Dining out strategies, Avoidance and treatment strategies for food allergy in school, House dust mite prevention strategies. These can be found under Management / Patient information sheets in the program.

B. More information:

“He can’t understand how much danger he is in. All he knows is that he is singled out, he’s different and that his mum and dad worry about him more than is good for them” - Parent of an allergic 5-year-old.¹

The profile of potentially fatal food allergies has altered very little in recent years. Improved medication has contributed to better quality of life for some, but allergy-related symptoms continue to restrict the lives of many. The same type of person is still at risk, typically a child in an atopic family that has a history of asthma, hay fever or other allergic conditions. Children tend to be the largest group of the population affected by food allergies (approximately 6-8% of children vs 1.5% of adults). Many of them outgrow their allergies, the great exceptions being peanut and tree nut allergy, which tend to be life-long. Improved public awareness has meant that allergic conditions are more widely recognized, but they are not necessarily better understood. Important role players, e.g. teachers, are not always knowledgeable or adequately supportive, resulting in increased pressure on parents of food-allergic children. Life with a food allergy remains difficult, with the only reliable therapy being complete restriction or elimination of the responsible food allergen and emergency management of reactions when allergens are accidentally ingested.^2,3,4,5

The diagnosis of food allergy in a child has an impact on every minute of every day for the person, and his/her family. The following is a summary of quality-of life-implications of food allergies for both the patient and the entire family.

1. Emotional and psychological effects

Psychologically, the child may be affected by food allergy through both direct and indirect mechanisms. Biological mediators of allergic reactions can directly affect the central nervous system. The stress of coping with a food allergy, e.g., through more complicated food selection and preparation, and through the fear of the consequences of ingesting the food again, can have an indirect impact. Indirect impact may also come through family members, e.g., when the parents are very fearful of normal interaction or inclusion of foods into the child’s diet.6

A Canadian study of the psychological burden of peanut allergy, as perceived by adults with peanut allergy and the parents of-peanut allergic children, indicated that peanut-allergic children suffered significantly more disruption in their daily activities than did other children.^5,7

In a study to determine the impact of food allergy on parental perceptions of physical and psychologic functioning, Sicherer et al. concluded that children with food allergy might experience significant impacts on their quality of life, such as poor general health perception, emotional distress in their parents, and stress in as well as limitations of family activities. Associated atopic disease (asthma and/or atopic dermatitis) and the number of foods being avoided were found to influence these reductions in quality of life.^3,4,8

Children with symptoms of atopy (e.g., eczema, asthma) may experience behavioral problems due to deprivation of active play with peers. This may result in deficits in some of the social training and adaptation needed in society.⁹ This is particularly apparent in children with chronic symptoms that effect sleep, resulting in either fatigue or paradoxical “hyperactivity”. These consequences are most often noticed in children with eczema and uncontrolled itching, and those with perennial hayfever causing constant nasal obstruction.

Calsbeek et al. investigated the consequences of having a chronic digestive disorder (such as inflammatory bowel disease, chronic liver disease, congenital disorders, coeliac disease and food allergy) on the social position of adolescents. Negative consequences were found to occur in education (absence from school, the need for remedial education), leisure activities (particulary as related to self-confidence), labor participation, financial situation, partnership and sexuality.⁹

Parents of allergic individuals are of course not spared psychological effects. A study by Arvola et al., which assessed concerns and expectations of parents of atopic infants, found that 90% of parents found the care of an atopic infant more demanding than that of a healthy child, due to the persistence of symptoms such as atopic eczema, pruritus and restlessness during sleep.¹⁰

Symptoms impacting on the child’s sleep and daily activities may result in stress in the parents, which in turn may result in a “psych cycle” whereby the parent projects his/her stress onto the child, resulting in exacerbation of the child’s stress and unhappiness. This further exacerbates the stress of the parent. In this instance, psychological counselling for the parent is essential. Occasionally, divorced parents may take contrary views on the requirements for a particular diet, the consequences being borne by the child. Grandparents have been known to give children restricted foods because they do not trust the diagnosis of food allergy.

To minimise the emotional and psychological effects, a number of strategies may be required. All potential allergen exposures should be anticipated and a reasonable, practical management and emergency treatment plan should be provided. Healthcare professionals need to continue to educate their patients, families, other relatives, other caregivers, schools, employers and the restaurant and food industry about the best evidenced-based approach to this clinical problem, to minimise the numerous obstacles faced.^3,4,5,11,12

Any elimination diet should have very rational and qualified indications, as a difficult elimination diet has serious societal implications – to say nothing of the risk of malnutrition. Food should not be seen only as nourishment for the body but also as part of our culture. Meals represent important occasions both in and outside the family. It is therefore imperative to eliminate only the offending food from the diet, thus avoiding unnecessary restrictions on a normal life. Families should be made aware of the natural history of food allergy, atopic eczema and asthma with regard to possible impacts on family dynamics, and vice versa.¹²

The vigilance required for allergen avoidance can have far-reaching consequences. Parents who feel unable to trust a third party to care for an allergic child may postpone or abandon plans to return to work. The family’s income is reduced or restricted, adding to the strain of actual medical expenses. Parents may feel obligated to accompany their child to every party, trip or outing, even if the child is able to cope without them. Tension may build up within the family, leading to arguments and accusations of inadequate vigilance.⁵

The patient and family must learn how to read labels, adapt recipes and educate other family members, childcare providers, camp counsellors and teachers. They must know how to recognize symptoms of a reaction and what to do during a reaction. Decisions such as which restaurant to go to and where to go on holiday will take on a new meaning. Education of the family with practical information is key, as it is possible to manage food allergies successfully while allowing the child to participate in common childhood activities. It is also necessary for parents to adopt a matter-of-fact approach, training children to identify and avoid culprit foods calmly from an early age.^5,13 Allergic children should be allowed to participate in normal activities and play as other children do. The risk of isolation, loneliness and maladjustment is obvious.⁹

2. Difficulties of food choice
Allergic children have restricted food choices. In a world full of interesting and convenient foods, a growing number of allergy sufferers take their lives in their hands every time they eat at sandwich bars, bakeries, and restaurants, or consume take-away and ready meals. Families with food allergy sufferers cannot eat out when or where they choose, buy the ever-increasing range of exotic take-aways or snacks on the market, or take holidays without planning carefully how they will avoid deadly food allergens. The allergy sufferer yearns to enjoy everyday foods, parties and luxuries without worrying, to be able to eat out knowing restaurant staff can handle their requests, and to have as many safe food choices as possible.⁵ This may be most important at school, where the allergic child witnesses the myriad of foods available that he or she may not have. Peer pressure to taste a new “food sensation” may be overwhelming.

For parents, extra time is required to purchase groceries and prepare meals. Many parents are unable to produce food from basic raw materials, and are dependent on utilising one or more processed products. Imagine a busy parent having to produce vegetable stock or butter from raw materials.2,14,15,16 In her Master’s dissertation, S. Matthee reported that parents’ level of basic nutritional knowledge had a major impact on the understanding and implementation of any form of diet for the child. The psychological stress of trying to cater for the demands of non-allergic children while accommodating the allergic child was enormous.

For parents and families, catering for a restricted diet when shopping or eating out depends on information which is often hidden or misleading. There has been a proliferation of “may contain” precautionary allergen labeling, with 28 different versions of this statement. The result is confusion, frustration and further food restriction for the allergic consumer. The situation has also contributed to the risk-taking behavior of certain groups such as teenagers.⁵

The role of the food manufacturer is crucial. Food ingredient statements must be easily understood. The information must be complete, truthful, consistent and reliable. There must be a minimal number of precautionary statements, visible clear and legible, with guidance from the industry regarding their meaning. Consumers must in the meantime, be aware of scientific names for problem foods. A recognized manufacturing standard should cause businesses to remove the risk of allergen cross-contamination. The integration of allergy into training for caterers and environmental health professionals would help food service businesses keep up to date.⁵ Within the important niche market of allergen-free products, manufacturers can provide more variety and better education.

3. Overprotection of the child
The severity of the allergic reaction tends to determine the societal implications. A parent who has experienced a severe anaphylactic reaction in his or her child may now feel entirely differently about that child. Fear and insecurity may invade family life. To the involved parent, it is usually impossible to know where to draw the line between too little and too much protection. Overprotection of the child can result. Parents and families often find it easier to cope with a static and stable physical handicap, which is apparent to other people and met with sympathy and understanding, than with more concealed and ambiguous handicaps such as allergic or atopic disease. In these cases, they can be confronted with a lack of understanding from relatives and friends.¹²

Parents may develop a fixation on the food-allergic child, with subsequent neglect of the needs of other children in the home; consequences may become apparent only in adulthood.

Every effort must be made to diagnose food allergies correctly and to educate patients on proper elimination diets. Parental obsession with food allergies is only reinforced when physicians fail to objectify experiences with proper testing, diagnosis and advice. In extreme cases, the obsession may present as Munchausen by proxy, which is a form of child abuse.2,18

4. Starvation, malnutrition (failure to thrive)
Allergies can have a long-term effect on a child’s nutritional status and growth. A study by Isolauri et al. evaluated the nutritional impact of therapeutic diets, including the risk factors predisposing infants with food allergy to poor growth. The mean length score and weight-for-length index of patients was lower than that of healthy age-matched children. Low serum albumin, abnormal urea concentration and low serum phospholipid docosahexaenoic acid was present in 6%, 24% and 8% of allergic patients respectively. The delay in growth was more pronounced in a subgroup of patients with early onset of allergy than in those with later onset of symptoms. The study also found that hesitation of families to introduce new foods, and food aversions acquired during the symptomatic periods, contributed to undernutrition. The study emphasized that a delicate balance exists between the benefits and risks of elimination diets.¹⁹

In addition, the wealth of information and misinformation easily accessible through the Internet and other popular media has led to allergies all too often being self-diagnosed and then treated with nutritionally inadequate diets.

5. Neophobia
A severe allergy or multiple food allergies can cause fear of trying new foods. A recent study by Rigal et al. explored the impact of an elimination diet in children with food allergy, and parents’ perception of the long-term reticence of their children to test unknown foods, or food neophobia (a normal phase in children between 1 and 10 years). The degree of food neophobia of children who had outgrown their allergy was compared to that of non-allergic siblings, using a standardized scale and a questionnaire on food friendliness. Parents were also asked to fill in a questionnaire on the disease and its burden on the family. Results showed that children who had outgrown their allergy were more reluctant to test new foods than their non-allergic brothers and sisters. Two factors increased the level of food neophobia: the duration of the period elapsed until the diagnosis was made (late diagnosis), and the lack of variety in meal preparation.²⁰

6. Poor compliance
Complete elimination diets have been shown to lead to the loss of clinical reactivity and the development of oral tolerance to many foods in about one third of children and adults after one to two years. But instituting a food elimination diet should be considered comparable to prescribing a medication in that both carry a definite risk-benefit ratio. Despite the therapeutic benefits associated with elimination diets in children with food allergies, these diets can be fraught with difficulties and complications (as is discussed throughout this article). Allergists and other healthcare professionals must recognize the enormous task and the emotional burden placed on patients and families by the prescription of elimination diets.^2,14,15,16

For children, the implementation of a restrictive diet may result in a very boring and dull diet. This may cause children to actively seek out alternative foods. This is particularly likely in homes where allergic children are fed meals that are significantly different from those of their siblings. In many instances, most commonly in children with eczema, very restrictive diets may result in severe stress, leading to worse symptoms than would have been provoked by a less restrictive diet.

Adolescents, specifically, pose an extreme challenge in the continuing management of allergic disease, as they often ignore allergen risk information. Those who die from food allergy are usually teenagers and young adults who suffer from severe allergic asthma or anaphylaxis after eating away from home. They tend to ignore “allergen traces” labeling and refuse to examine ingredient labels, believing that manufacturers are only using them to “cover their backs.”5,9

Deaths and near-fatalities are often caused by misunderstanding, misinformation, assumptions and guesses both by food professionals and allergic customers. In many cases, no proper clinical diagnosis had been given and the young person was untrained or ill-equipped in allergy survival.⁵

Given the poor compliance that can occur even in necessary elimination diets, it is all the more crucial not to impose unneeded and even dangerous dietary burdens. An unusual case has been reported of an adolescent girl who died from anaphylaxis to milk proteins due to a presumed loss of tolerance after an inappropriate exclusion diet.²¹ A recent study examined the inappropriate diagnosis of food allergy in children with atopic eczema dermatitis syndrome (AEDS) and the development of acute allergic reactions after prolonged cow's milk elimination diets. The study concluded that a considerable chance exists of developing acute allergic reactions to CM after prolonged and unnecessary elimination in children with AEDS but no previous reactions to CM.²²

The role of the dietitian
The study by Arvola et al. cited above, which assessed concerns and expectations of parents of atopic infants, found that parents advocated diagnostic evaluation and the elimination of specific foods from the diet of the lactating mother in the management of these problems. They expected accurate diagnosis of food allergies, practical advice on elimination diets, alleviation of symptoms and follow-up of growth and nutrition, and they considered the care provided by the intervention team to suffice in these aims. The study therefore supports a comprehensive, multidisciplinary team approach to providing care for atopic infants and their parents.¹⁰

Although avoiding food allergens appears to be a simple procedure, in practice it can result in a multitude of nutritional, social and psychological problems. Professional dietary advice should be regarded as mandatory, as the risks associated with nutritional inadequate diets may far outweigh any benefits.²³

The dietitian can do a complete dietary assessment to ensure that sufficient nutrients are provided to promote appropriate growth and development in children. The dietitian can also help educate parents and siblings in reading labels of processed foods, provide appropriate recipes and generally promote compliance on the part of both patient and parent. The dietitian can assist in making the diet more varied, interesting and practical for each patient and family’s individual situation. It is essential that the child does not feel “different.” The psychological impact of a restriction diet on the child’s social development must always be considered. Options as well as coping mechanisms should be given for school, for parties and for other social occasions. Assessment of the quality of the diet and the degree of compliance prevents unnecessary lengthening of time on a particular elimination diet due to non-compliance, as well as nutritional inadequacy.^16,24,25

Medical staff, including dietitians, allergists and nurses or nursing sisters, should actively assist parents as they help their children take responsibility for their own healthcare and develop positive self-images. Nutrition plans should set realistic goals and provide for ongoing support and encouragement. ^16,24,25

Management and treatment should include a multidisciplinary approach to support and strengthen the family. There should be an optimistic and constructive philosophy, and insight into both the disorder (kind and degree of allergy) and the family dynamics. It is important to understand the role in the family of the affected child’s siblings as well as any feelings of guilt or worry over financial, household and family responsibilities experienced by parents. Ultimately, the balance must be found between efforts to mitigate the disease and to sustain the overall quality of life.^12,16

C. Comments by our editors

Prof Janice M. Joneja Ph. D., RDN The case study featured this month is typical of a scenario with which everyone who has counselled parents and care-givers of food-allergic children is extremely familiar: How does one communicate the necessity of avoiding the child’s allergenic foods without creating anxiety in the care-givers? Anxiety all too often leads to extreme diligence in avoiding the child’s allergens, frequently leading to unnecessary dietary restrictions with the consequent risk of malnutrition. This discussion gives a good, balanced view of the problem and provides some excellent guidelines for management, especially with regard to the importance of a team approach. The child in this study was lucky to have such a caring and dedicated health care team willing and able to provide support in a timely manner. Many children, especially in rural areas far from the facilities and expert personnel that major cities provide, are rarely so fortunate! Some interesting pieces of information from recent medical literature provide a little more insight into aspects of paediatric food allergy alluded to in the discussion: • Early food allergies, even to highly allergenic foods such as peanuts, are outgrown more frequently than previously thought: Evidence: In 2001 paediatric allergists in the U.S. reported that about 21.5 per cent of children will eventually outgrow their peanut allergy (Skolnick et al 2001), and those with a mild peanut allergy, as determined by the level of peanut-specific IgE in their blood, have a 50% chance of outgrowing the allergy (Fleischer et al 2003). In contrast, only about 9% of patients are reported to outgrow their allergy to tree nuts (Fleischer et al 2005). • Eating a food regularly will maintain tolerance to it, whereas strict avoidance for a prolonged period of time has the risk of sensitising the atopic person to the food when it is consumed in the future. This applies even if a person has been allergic to the highly allergenic peanut proteins, but has outgrown the allergy: Evidence: Studies indicate that when there is no longer any evidence of symptoms developing after a child has consumed peanuts, it is preferable for that child to eat peanuts regularly, rather than avoid them, in order to maintain tolerance to the peanut. Children who outgrow peanut allergy are at risk for recurrence, but the risk has been shown to be significantly higher for those who continue to avoid peanuts after resolution of their symptoms (Fleischer et al 2004). References: Fleischer DM, Conover-Walker MK, Christie L, Burks AW, Wood RA. The natural progression of peanut allergy: Resolution and the possibility of recurrence. J Allergy Clin Immunol; 2003;112(1):183-189 Fleischer DM, Conover-Walker MK, Christie L, Burks AW, Wood RA. Peanut allergy: Recurrence and its management. J Allergy Clin Immunol 2004;114(5):1195-1201 Fleischer DM, Conover-Walker MK, Matsui EC, Wood RA. The natural history of tree nut allergy. J Allergy Clin Immunol 2005;116(5):1087-1093 Skolnick HS, Conover-Walker MK, Koerner CB, Sampson HA, Burks W, Wood RA. The natural history of peanut allergy. J Allergy Clin Immunol 2001;107(2):367-374

Dr. Harris Steinman M.B.Ch.B. This review, combined with Prof. Joneja's comments, should sensitise the reader to a very important aspect to consider when evaluating children with allergy. Although this review is primarily directed towards an aspect of food allergy in children, clinicians will recognize similar patterns in adults. Adult patients with food allergy may have an overwhelming fear for an anaphylactic reaction, even when prior adverse reactions were mild.

For more information on this subject and other allergy- and intolerance-related topics, visit:
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http://users.bigpond.net.au/allergydietitian

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D. References
1. Weale S. Shell Shock. The Guardian (Weekend) June 24th, 2000;: 26-33
2. Metcalfe D, Sampson, H, Simon R. Food Allergy: Adverse reactions to foods and food additives, Second edition. Blackwell publishing 1997. Chapter 32 p461
3. Sicherer SH, Noone SA, Munoz-Furlong A. The impact of childhood food allergy on quality of life. Ann Allergy Asthma Immunol. 2001 Dec; 87 (6): 461-464
4. James JM. Guest editorial. Food allergy and quality of life issues. Ann Allergy Asthma Immunol. 2001 Dec; 87 (6): 443-444
5. Gowland MH. Food allergen avoidance – the patient’s viewpoint. Allergy 2001; 56 Suppl 67: 117-120
6. Kelsay K. Psychological aspects of food allergy. Curr Allergy Asthma Rep. 2003 Jan; 3 (1): 41-46
7. Primeau MN, Kagan R, Joseph L et al. The psychological burden of peanut allergy and the parents of peanut allergic children. J Clin Exp Allergy 2000; 30: 1135-1143
8. Cohen BL, Noone S, Munoz-Furlong A, Sicherer SH. Development of a questionnaire to measure quality of life in families with a child with food allergy. J Allergy Clin Immunol. 2004; 114: 1159-1163
9. Calsbeek H, Rijken M, Bekkers MJ et al. Social position of adolescents with chronic digestive disorders. Eur J Gastroenterol Hepatol. 2002 May; 14 (5): 543-549
10. Arvola T, Tahvanainen A, Isolauri E. Concerns and expectations of parents with atopic infants. Pediatr Allergy Immunol. 2000 Aug; 11 (3): 183-188
11. Rhim GS, Mc Morris MS. School readiness for children with food allergies. Ann Allergy Asthma Immunol. 2001 Feb; 86: 172-176
12. Aas K. Societal implications of food allergy: coping with atopic disease in children and adolescents. Ann Allergy 1987 Nov; 59 (5 part 2): 194-199
13. Munoz-Furlong A. Daily coping strategies for patients and their families. Pediatrics 2003 Jun; 111 (6 part 3): 1654-1661
14. Sampson HA, Scanlon SM. Natural history of food hypersensitivity in children with atopic dermatitis. J Pediatr. 1989; 115: 23-27
15. Pastorello EA, Stocchi L, Pravettoni V et al. Role of elimination diet in adults with food allergy. J Allergy Clin Immunol. 1989; 84: 475-483
16. Motala C, Stear G. Challenge testing and elimination diets in food allergy. Practical and nutritional considerations. The Specialist Forum 2003 May; p16-28
17. S Matthee. The development of nutritionally adequate two-week menu cycles for households with children allergic to wheat, soy, cow's milk and egg respectively. Master Thesis. Department Consumer Science, University of Stellenbosch. Stellenbosch. South Africa. October 2002
18. Warner JO, Hathaway MJ. Allergic form of Meadow’s syndrome (Munchausen by proxy). Arch Dis Child 1984; 59: 151-153
19. Isolauri E, Sutas Y, Salo MK et al. Elimination diet in cow’s milk allergy: risk for impaired growth in young children. J Pediatr. 1998 Jun; 132 (6): 1004-1009
20. Rigal N, Reiter F, Morice C, De Boissieu D et al. Food allergy in the child: an explanatory study on the impact of the elimination diet on food neophobia. Arch Pediatr. 2005 Dec; 12 (12): 1714-1720
21. Barbi E, Gerarduzzi T, Longo G et al. Fatal allergy as a possible consequence of long-term elimination diet. Allergy 2004; 59: 668-669
22. Flinterman AE;Knulst AC;Meijer Y;Bruijnzeel-Koomen CA;Pasmans SG; Acute allergic reactions in children with AEDS after prolonged cow's milk elimination diets. Allergy 2006 Mar 61(3):370-374
23. Wolfe SP. Prevention programmes – a dietetic minefield. Eur J Clin Nutr 1995; 49 (Suppl.1): S92-S99
24. Carroll P, Caplinger KJ, France GL. Guidelines for counseling parents of young children with food sensitivities. J Am Diet Assoc. 1992 May; 92 (5): 602-603
25. Mofidi S. Nutritional management of pediatric food hypersensitivity. Pediatrics 2003 June; 111(6) : 1645-1653


E. CEU Questions (For South African dietitians only. Australian dietitians: where you have relevant learning goals, CPD hours related to this resource can be included in your APD log.)

PLEASE ANSWER ALL THE QUESTIONS
(There is only one correct answer per question.)

1. The only reliable therapy for food allergic reactions consists of:
a. Complete elimination of the responsible food allergen
b. Emergency management and partial elimination of the responsible food allergen
c. Complete elimination of the food allergen and emergency management
d. None of the above

2. True or false: Indirect impacts of food allergy on the patient include biological mediators which affect the central nervous system.
a. True
b. False

3. Food allergy may impact on a child’s quality of life in the following areas:
a. Poor general health, severity of atopic dermatitis and concentration at school
b. Good general health perception, positive interactions on family activities
c. Poor general health perception, emotional distress and stress in their parents, limitations of family activities
d. Easier food choices and minimal emotional stress in their parents as well as normal family activities

4. How many different versions exist of the statement “may contain” precautionary allergen labeling?
a. 24
b. 82
c. 22
d. 28
e. 30

5. True or false: In a study evaluating the nutritional impact of therapeutic diets, low serum albumin, abnormal urea concentration and low serum phospholipid docosahexaenoic acid levels were present in 6%, 24% and 8% of allergic patients respectively.
a. True
b. False

6. Two factors increased the level of food neophobia in food allergic children once the allergy had been outgrown.
a. Early diagnosis and the distressing effect of attending the allergy clinic
b. Late diagnosis and lack of variety in meal preparation
c. Early diagnosis and variety in meal preparation
d. Distress of eating with the rest of the family and the fear of developing a reaction

7. Which group poses an extreme challenge in the continued management and treatment of allergic disease?
a. Infants and toddlers
b. School-going children
c. Adolescents and teenagers
d. Parents
e. Caregivers

8. Professional advice from which healthcare professional should be regarded as mandatory in the management and treatment strategy for an atopic child?
a. Dietitian
b. Paediatrician
c. Clinic sister/nurse
d. Gastroenterologist
e. Occupational therapist

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Impact of food allergy
CEU Activity Reference Number: DTA06/02/001

HPCSA number: DT
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This issue was sponsored by Abbott Laboratories S.A (PTY) LTD All Abbott products are lactose and gluten free Tel: 011-8582054