Case 1 (a teenage girl with anaphylaxis to peanut)
Lisa was referred to the allergy specialist dietitian by the paediatrician because of episodes of abdominal pain and cramps with increasing severity and several food allergic reactions over the years. The family attributed these reactions to peanut, because she was diagnosed with peanut allergy since she was young. However, they had been avoiding peanut strictly.
The paediatrician recently updated the information on sensitization to foods and inhalant allergens. Sensitization to inhalant allergens was negative, sensitization to foods was positive for the following foods: hazelnut 0.61
kU/L, peanut 76.2
kU/L, pistachio 7.14
kU/L, soy 2.72
Sensitisation to coconut, almond, cashew nut, milk, egg, fish, and wheat was negative.
Clinical and Allergy-Focused Diet History. There is a positive family history of atopy and asthma in her father's family. The clinical history revealed that she has suffered from abdominal pain since she was very young. She reported increasing episodes of having cramps and nausea. She has asthma which was under good control. She was carrying an epipen for her peanut allergy, however, was not confident about using it.
Firstly, the diet history focused on the clinical relevance of the foods sensitized to and on excluding dietary errors on peanut ingestion.
Lisa has been trying to avoid peanuts and other nuts since she was young. The family read labels and try to avoid foods containing peanut and nuts. Foods with advisory labeling for peanuts and nuts were avoided.
Over the years, several allergic reactions occurred after eating a food or meal, of which the family thought that peanut must have been the causative ingredient. The reactions did not occur immediately. Remarkably, most reactions, except the reaction to M&Ms, were preceded by a form of exercise after eating (gym, playing outside, karate lessons) or stress (school party).
- When she was much younger she reacted to M&Ms with vomiting.
- When she was 11 years old, she had an anaphylactic reaction following a home made Indonesian meal without nuts or peanut, for which she used her epipen. The meal included tofu and soy sauce.
- Last year, at a school party, she reacted with swollen lips, itchy ears, and dyspnoea after eating a chicken nugget.
- A few months ago she reacted with swollen lips, tachycardia, and presyncope after eating meat coated with bread crumbs.
- Over the years there were several reactions of tachy- cardia, abdominal pain with cramps, and lip swelling having had commercially prepared meat products.
- On one occasion she had a hazelnut and a cookie with almonds without symptoms.
Secondly, the diet history focused on the nutritional composition of the food to rule out any over or under consumption of foods, because cramps and nausea may be related to fibre consumption. Lisa's diet, however, seems to be sound with no nutritional imbalances.
The dietitian also suspected the sensitisation to soy to be of clinical relevance and suspected exercise-induced anaphylaxis to soy. The paediatrician agreed with this, and the dietitian advised Lisa and her family to avoid not only peanuts and nuts, but also soy protein. Soy protein was incorporated in the Indonesian meal and could have been incorporated in the chicken nuggets, coated meat with bread crumbs, and commercially prepared meals.
Results. No anaphylactic reactions occurred from that point forward, and the complaints of abdominal pain, cramps, and nausea disappeared. The dietitian advised to continue avoiding peanuts, nuts, and soy protein and to take particular care when exercising. The avoidance of all other nuts needed further consideration. The paediatrician/allergy nurse updated the information and the use of the adrenaline autoinjector.
- An allergy specialist dietitian can sustain the diagnosis in taking an allergy-focused diet history.
- The diet history is the cornerstone of the diagnosis of food allergy and may direct the nature of the foods to be avoided.
- The dietary history may reveal if chronic symptoms may be caused by a deficient or unbalanced diet and if external factors may play a role, such as, exercise.
Reason for Referral to an Allergy Specialist Dietitian. In many countries, access to the dietitian is limited, and allergy specialist dietitians are scarce.
Referral is specifically important:
- when an allergy-focused diet history is required to examine if certain foods provoke symptoms or, in case of chronic symptoms, these complaints may be caused by a deficiency or imbalance in the diet;
- when nutritional adequacy of the diet is questionable and needs to be checked, for example, in case of avoidance diets in young infants and toddlers (specifically cow's milk free and wheat free diets), multiple food allergy, picky eaters, faltering growth, and when symptoms do not improve despite adequate medication;
- when counselling and nutritional management are required, for example, in patients having questions about the practical implication of the avoidance diet (replacements of foods, social activities, school meals, school camps, holidays), allergic reactions despite following an avoidance diet, anxiety to food, and overrestriction of foods.
Case 8 (11 months old boy with multiple food allergies)
- Oscar was referred to the allergy specialist dietitian by the paediatrician because of acute urticaria and angioedema after ingestion of egg and growth faltering. Skin prick test results indicated;
- egg allergy (8mm SPT);
- peanut sensitisation (SPT 4mm);
- no other positive SPT/IgE for milk, wheat, fish, soy.
Clinical History. There is a positive family history for atopy and asthma in both families. The clinical history reveals that he has suffered from eczema from about 2-3 months. He also has “loose” stools but does not wheeze.
Allergy-Focused Diet History: Enquire about Breastfeeding, Formula Feeding and Weaning onto Solids, and If Any Reactions Occurred. Oscar was breastfed until 6 months and received a top-up drink of cow's milk formula from 1 month of age. Solids were introduced at 5 months starting with baby rice, vegetables, and fruit. At six months gluten was introduced then chicken, lamb, fish, and lentils. No reactions were noticed to these.
Enquire about the Introduction of the Major Allergenic Foods
- Milk given from 1 month and mother did not avoid milk during lactation with no noticeable reactions.
- Wheat was introduced at 6 months with no noticeable reactions.
- Fish was given at about 7 months with no noticeable reactions.
- Egg was given at 10 months when he had the reaction.
He has not had peanut, tree nuts, sesame seeds, shell fish, molluscs, mustard, celery (although she thinks it might have been in a stew she made), lupin (although difficult in the UK to know which foods contain these), soya (not sure but as she cooks everything at home it seems to be unlikely).
General Diet History.
Mother offers 3 meals per day which are nutritionally balanced, but he has always been a “difficult feeder”. He has breakfast most days (baby rice with apple) but often refuses lunch (usually have 1/
2 banana) and needs distraction most meal times but may eat about 90
g of dinner with pasta/rice/potato, meat, and mixed vegetables.
He has 350 mL/day of formula, which he drinks in 5-6 bottles of 60 mL/bottle.
Dietary Assessment. There are some concerns about his intake of protein and energy (60% of required calculated intake), iron (75% of UK RNI), calcium (51% of UK RNI), and vitamin D (60% of UK RNI).
Initial Dietary Intervention
The initial dietary consultation included advice on an egg and nut-free diet. It was felt that the diagnosis of egg allergy was clear. The peanut result clearly only indicated sensitisation at this stage rather than clinical allergy as he has not consumed peanut until now, but it was felt that he was too young for a peanut challenge.
The formula was changed to an energy dense formula of 100
mL and 2.5
mL. A normal infant formula contains approx 67–79
kcal/mL and 1.4–1.7
g of protein. Mother was also advised to further increase his protein, kcal, and calcium intake with cheese and to add double cream to sauces. Meal times should be kept to 30
min and a long consultation about dealing with faddy eating, including, practical tips follows. No force feeding was allowed and mother was asked to allow time for messy play. Inclusion of red meat (iron) and fatty fish (vitamin D) when possible was recommended, but these deficiencies should be corrected by taking sufficient formula, to initially aim to increase formula to 500
mL per day, which would not provide all the nutrients he needs but a step in the right direction.
After Dietary Intervention
After the dietary intervention, his volume of feed was reduced and he was only managing 30
mLs per bottle that is about 180
mL per day. His “difficult feeding behaviour” turned into extreme food refusal, and he was crying during and after feeds showing clear signs of discomfort. His eczema also seemed to flare after every meal. He stopped gaining weight.
Results: Followup and Current Intervention
He started on a cows' milk and soya-free diet and changed formula to amino-acid-based formula. The decision about soya avoidance was based on the concomitant soya allergy seen in children with gut symptoms and a non-IgE-mediated (in this case) milk allergy. His eczema cleared completely, feeding standard improved, and he started to gain weight again. The patient is currently on egg- and nut-free diet with plans to review the nut-free diet and possible challenge after 12 months. Both the suspected milk and soya allergies also need to be confirmed by challenge, but there are currently no standardized procedures for performing food challenges in children with non-IgE-mediated food allergies.
- An allergy specialist dietitian can support the diagnostic process and may identify other nutrition-related issues.
- The diet history forms an important part of the diagnosis of food allergy and may direct the nature of the foods to be avoided particularly in the case of infants foods involved in delayed symptoms.
- The diet history may reveal any deficiencies which may relate to growth and development problems in infants.
Reasons for Referral to Dietitian
The dietitian can assist in and plays a crucial role in:
- taking an allergy-focused diet history;
- identifying any additional feeding problems either behavioural or nutritional;
- assessing nutritional intake and nutritional status;
- dietary management of any issues surrounding growth;
- practical advice on food avoidance and suitable replacements which can include:
- foods to avoid;
- label reading;
- suitable substitute foods for example, egg replacers/suitable infant formulas;
- recipe adaptation and suitable cook books;
- internet resources;
- support groups;
- assistance with design of food challenges;
- with young children having feeding difficulties when being weaned;
- in pregnant and lactating women following an avoidance diet for more than a few weeks, when losing weight involuntarily or when they consider stopping breastfeeding due to lack of dietary counselling and/or decrease in breast milk production.
Case 8 (a boy with severe eczema associated with multiple food allergies)
Jack presented at the allergy centre at age 3 months with severe eczema covering a large area of his body and face. A detailed history revealed that he had been born at full term, with a normal delivery. Jack was exclusively breastfed and his weight was between the 25th and 50th centile. His family history included asthma and hay fever in both parents. Following consultation with a paediatrician and a dietitian, Jack's mother was given information on skin care for eczema, in line with NICE guidelines [18
]. Although she did not want him to have skin prick tests (SPT) at this stage, she was advised on avoidance of foods that commonly cause allergic reactions in breastfed infants, and she agreed to begin a diet excluding cow's milk and egg. In addition, advice on low-allergen weaning was provided, as Jack's mother wanted to start introducing solid foods in the coming months.
When Jack returned to the clinic at age 6 months, his mother was successfully avoiding dairy and egg. She had read advice that rice milk should be avoided for babies and toddlers, and she was drinking soya milk instead, consuming more than 500
mL each day. Jack's eczema was improving but not completely cleared, and his weight had dropped below the 25th centile. His mother also felt that he was irritable and not keen on feeding. Jack was otherwise well, with a normal physical examination and full blood count.
Jack had begun weaning at age 17 weeks, with baby rice, fruit, and vegetables. He had accidentally been given fromage frais (contains milk) by a relative and had experienced a severe immediate reaction, involving swelling of his lips and tongue, red facial flush, hives on his chest, and wheezing. Indeed, SPTs at age 6 months confirmed that Jack was sensitized to a number of foods, including milk, egg, and soya.
Given Jack's ongoing symptoms and his positive SPT to soya, the paediatrician advised his mother to begin excluding soya from her diet, while continuing to avoid egg and dairy. Jack's mother was feeling worn out by the constant effort of checking food labels and managing Jack's eczema and irritability. Consequently, she wanted to introduce a formula feed at bedtime, and an amino-acid-based formula was prescribed. Written information was provided explaining that it could be expected to taste and smell different from other formulas, and also that the change in diet may alter stool colour and consistency. If required, to aid introduction, we advised that it could be mixed with breast milk, pointing out that mixed feeds must be used immediately to avoid possible digestion by enzymes in the breast milk. Additionally, all foods, excluding dairy, egg, soya, and peanut, could be introduced into Jack's diet, one at a time.
Jack's mother initially introduced amino-acid-based formula in a 30
70 mix with breast milk. The proportion of formula was gradually increased and within a few days, Jack was taking full formula feeds. At age 9 months, Jack's weight had increased to just below the 50th centile and he had a varied diet of solid foods, with breast milk and night-time feeds of amino-acid-based formula. Jack's mother was also adhering well to the exclusion diet and was taking calcium and vitamin D supplements. At age 12 months, his weight was on the 75th centile. Two days prior to the appointment, he had a reaction after eating hummus, despite the fact that his mother was eating hummus regularly and he was still receiving breast milk. The symptoms included swollen lips and a red facial flush, though there was no wheezing this time. SPTs at age 12 months confirmed that he was sensitized to sesame, among other foods.
We advised that Jack and his mother should exclude sesame from their diets, while continuing to avoid dairy, egg, and soya.
Jack's progress will be monitored at 6 to 12 monthly intervals, as appropriate. At each follow-up visit, SPTs and records of accidental ingestion will be used to determine whether oral challenges should take place. Deciding when to challenge can be difficult and should take into account both the clinical factors discussed here and the family's readiness, as the process can cause anxiety and emotional distress. A negative oral challenge for a given food will then enable recommendation of its introduction to Jack's diet. Clinical reactivity to milk and sesame has been confirmed by the reactions during oral exposure. The diagnosis of egg and soya allergy at this stage is based on sensitisation and improvement of symptoms after avoidance but will need to be confirmed by oral food challenges under medical supervision.