DIETS FOR DIAGNOSIS AND MANAGEMENT ACROSS THE SPECTRUM OF IGE AND NON- IGE MEDIATED FOOD ALLERGIES - CARINA VENTER PHD RD
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OCTOBER 2017 Diets for diagnosis and management across the spectrum of IgE and non- IgE mediated food allergies Carina Venter PhD RD
Overview • Nomenclature • Dietary management • Elimination • Diagnostic phase • Management
Learning objectives
• Understand the nomenclature used in all the different forms
of food allergy
• Be able to explain and use dietary measure in the diagnosis
and management of all the different forms of food allergy
• Understand the role of primary care in the management of
food allergy, particularly cow's milk allergy
3
The National Institute of Allergy and Infectious Diseases (NIAID) defines a food allergy as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.” Definitions/Nomenclature - you can not really manage a disease if you do not know what you are dealing with…
The differences
between IgE and
non-IgE mediated
food allergies
5
Eosinophilic Esophagitis is a form of:
1) IgE mediated food allergy
2) Mixed patters of IgE and non-IgE mediated food allergies
3) Non-IgE mediated food allergy
4) Food intolerance
6
Different types of food allergy
Food allergies
Non-IgE
IgE mediated
mediated food
food allergies
allergies
Food Protein induced enterocolitis
Other forms of non-IgE mediated food allergies
UK NICE guidelines 2011
Simon et al. 2016
Eosinophilic Esophagitis
Nowak-Wegzrsyn et al. 2017
Lucendo et al. 2017
Boyce et al. 2010
Mild to moderate non-IgE mediate food allergy
7
Dietary management
• History
• Diagnostic phase: Food
elimination followed by Food
reintroduction/trial or
“challenge” phase
• What your real
doc doesn’t know
• Management phase – Dr. Google will!IgE mediate food allergies - history
• Dietary focused allergy history
• Symptoms within 2 hours of
consumption
• Foods 14 major allergens
Skypala et al. Clin Transl Allergy. 2015;5:7.Non-IgE mediated food allergies - history
FPIES Other Mild-moderate EGIDS (EoE)
History important History less History can be History less
helpful helpful helpful (often not
corresponding
with
clinicopathologica
l findings)
Vomiting 1-4 Symptoms and Symptoms and Symptoms and
hours after timing of timing of timing of
consumption of presentation presentation presentation
allergen varies varies varies Nowak-Wegzryn et al. 2016
Venter and Groetch 2014
Groetch et al. 2017
Venter et al. 2017
Meyer et al. 2015 & 2016
Lucendo et l. 2016
Spergel et al. 2012
Caubet et al. 2014Non-IgE mediated food allergies - foods
FPIES Other Mild-moderate EGIDS (EoE)
Milk Milk Milk Milk
Rice Soy Soy Wheat
Soya Egg Wheat Egg
Oats Wheat (Egg) Soy
Fish/Shellfish Rice Corn
Poultry/Beef Potato Beef
Barley Fruit and Vegetable Chicken
Sweet potato Peanut
Egg Potato
Wheat Pork
Rice
Nowak-Wegzryn et al. 2016
Venter and Groetch 2014 Meyer et al. 2015 & 2016
Groetch et al. 2017 Lucendo et l. 2016
Venter et al. 2017 Spergel et al. 2012
Caubet et al. 2014Eve is 6 months old and on a cow’ milk formula:
has intermittent vomiting, fussy eater, faltering
growth and eczema. She most likely suffers from:
1) IgE mediated cow’s milk allergy
2) Eosinophilic Esophagitis
3) Food protein induced enterocolitis
4) Lactose intolerance
12The NICE Guideline
‘Diagnosis and Assessment
of Food Allergy in Children
and Young People in Primary Care and
Community Settings’
13• Personal History (asthma, eczema, rhinitis)
• Atopic Disease in family – parents, siblings
• Foods avoided and why (child and family)
• Who suspects what allergen?
• Feeding History
• List of possible symptoms
• Response to treatments eliminations and
reintroductions
AskInitial Recognition/Suspicion
The NICE
Diagnostic Allergy-focused History
Pathway
2011 When to consider early referral
Food allergy is suspected
Information to be given
IgE allergy is suspected Non-IgE allergy is suspected
Consider referralWho / When to refer
(before testing)
• Acute systemic reactions or Severe delayed
reactions
• Faltering Growth and Gastrointestinal
Symptoms
• Significant Atopic Eczema with suspicion of
multiple food allergies
• Possible multiple food allergies
NICE 2011Referal (after testing) • Proven IgE reaction and ASTHMA • Tests negative but history gives strong clinical suspicion of IgE mediated allergy • Symptoms that do not respond to single allergen elimination diet • Persisting parental suspicion of food allergy but unconvincing history • Patient not improving on ”standard care”
CKS on CMA in Primary Care
2015
‘ NICE recognises that the expertise to choose,
perform and interpret tests for suspected IgE-
mediated milk allergy may not be readily
available in primary care; therefore the
diagnosis and management is more likely to be
done in secondary care.’Nice CKS CMA Referral
Clinical expression Referral Guidance
Mild Should be managed in
to Primary Care
Moderate Non-IgE With on-going dietetic support
Unless there is no improvement
Severe Non-IgE Prompt specialist referral of all
Now- NICE implies
Mild
Prompt referral of most / ?all
to
(unless you can test and know how to interpret)
Moderate IgE
Emergency care – if indicated
Severe IgE
Then
(Anaphylaxis)
Prompt specialist referral of allDiagnostic phase
IgE mediated
food allergies
• Skin prick tests
• Specific IgE tests
• Component resolved diagnostic tests
• Initial food avoidance
• Complete avoidance of the suspected
allergen
• Food challenge
21IgE mediated food allergies: Standardized Food
challenge
Sampson et al. J Allergy Clin Immunol. 2012;130(6):1260-1274
Nowak-Wegzryn et al. J Allergy Clin Immunol. 2009; 123:S365-83Milk Challenge
“Usual ” OFC Higher risk OFC (DBPCFC)
• 10 g of dried, non fat milk powder (DBPCFC)
= 6 ½ oz ml of milk (open OFC) 5% 0.1%
10% 0.5%
• PRACTALL: (4.443 g protein)
12.428 g of skimmed milk powder 15% 1%
(8.3 mg; 27.8 mg; 83.3 mg; 277.8 mg; 833.3 mg; 2777.8
20% 4%
mg; 8333.3 mg)
25% 10%
Milk: 25% 20%
• 6-8 oz milk or infant formula
20%
• ½-1 cup yoghurt or ice cream
20%
• ½-1 cup cottage cheese
• ½-1oz hard cheese 24%
• Baked milk challengesNon-IgE mediated
food allergies
• No tests
• Initial food avoidance
• Food challenge/reintroduction
24Non-IgE mediated food allergies
FPIES Other Mild-moderate EGIDS (EoE)
Tests No tests No tests No tests No tests (perhaps…SPT
and patch test up to
65% indicative of
causative foods)
Identifying the Food avoidance Food avoidance Symptoms and timing of Symptoms and timing of
offending food presentation varies presentation varies
Can use elemental, one,
two, four or six food
exclusion diets..
Initial elimination Until the food challenge Until the food (4 Food avoidance (2-4 Until the next
period or indefinite weeks) challenge or weeks) followed by endoscopy
indefinite reintroduction
(endoscopy may be
required)
Food challenge vs. Food challenge Food reintroduction Food reintroduction Food reintroduction
reintroduction Venter et al. 2017
followed by endoscopy
Meyer et al. 2015 & 2016 Nowak-Wegzryn et al. 2016
Lucendo et al. 2016 Venter and Groetch 2014
Groetch et al. 2017If Eve actually suffered from food protein induced
enterocolitis: would you perform a SPT and/or a
specific IgE tests?
1) Yes
2) No
26• Total dose range of 0.06-0.6 g protein/kg
body weight (usual dose 0.15-0.3) to
max of 3 g of protein or 10 g of whole
FPIES – Food food
• Give in 3 divided doses over 45 minutes
challenges • Patients with history of severe reaction,
start with smaller dose of 0.06 g/kg.
• Observe for 4 hours; if no reaction, give
second dose of appropriate single
serving and observe for 2-3 hrs
Nowak-Wegzryn et al. Curr Opin Allergy Clin Immunol. 2014;14
:250 – 254.A Practical Example of a Reintroduction in a Formula Fed Child
The Volume of Hypoallergenic Cow’s Milk
Days Boiled Water Formula Formula
mls. (fl. oz.) mls. (fl. oz.) mls. (fl. oz.)
Reintroduction Day 1 210 mls. (7 fl.oz.) 180 mls. (6 fl.oz.)
in 1st bottle only
30 mls. (1 fl.oz.)
in 1st bottle only
of milk: Mild to Day 2 210 mls. (7 fl.oz.) 150 mls. (5 fl.oz.)
in 1st bottle
60 mls. (2 fl.oz.)
in 1st bottle
moderate non-
Day 3 210 mls. (7 fl.oz.) 120 mls. (4 fl.oz.) 90 mls. (3 fl.oz.)
in 1st bottle in 1st bottle
IgE CMA
Day 4 210 mls. (7 fl.oz.) 90 mls. (3 fl.oz.) 120 mls. (4 fl.oz.)
in 1st bottle. in 1st bottle
Day 5 210 mls. (7 fl.oz.) 60 mls. (2 fl.oz.) 150 mls. (5 fl.oz.)
in 1st bottle in 1st bottle
Day 6 210 mls. (7 fl.oz.) 30 mls. (1 fl.oz.) 180 mls. (6 fl.oz.)
in 1st bottle in 1st bottle
Day 7 210 mls. (7 fl.oz.) 0 210 mls. (7 fl.oz.)
in 1st bottle
If no symptoms occur after Day 7, when you have replaced the 1st bottle of the day completely with cow’s milk
formula, give your child cow’s mik formula in all bottles.
28
Fully Breast Fed ChildFOOD(TRIAL(“DO’S”(
! Do(offer(the(trialed(food(s)(at(least(5(days(per(week,(if(not(daily(
! Consume(at(least(2(tablespoons(or(an(ageRappropriate(serving(size(of(trialed(food(daily(
! Consult(Dietitian(when(food(trial(choices(are(limited(or(before(decreasing(supplemental(formula((
! STOP(the(food(if(symptoms(develop(and(contact(the(nurse(for(further(guidance(
( • How many foods should be
(( reintroduced at a time or before the
next endoscopy?
Food trials
(
• What is the period of time for
• Consume(for(12(weeks( reintroducing each food?
Eosinophilic
1st(Food(
• If a patient does become symptomatic,
should food reintroduction be
• >(15(eos/hpf(⇒(FAIL(⇒(6(week(wash(out( discontinued?
Esophagitis: Six EGD$ • (15(eos/hpf(⇒(FAIL(⇒(6(week(wash(out(
EGD$ •Long-term food
eliminationManagement • Longer term avoidance • Formula choice in terms of cow’s milk allergy • Level of avoidance required • Nutritional deficiencies • Growth and development • Feeding skills • Quality of life
Longer term food elimination
IgE mediated FPIES Other non-IgE Mild-moderate EGIDS (EoE)
food allergies food allergies
How long should Depends on Depends on food Depends on food Reintroduction Food
the food be food, tests and and presentation and presentation recommended reintroduction
avoided? presentation after 6 months followed by
of avoidance or endoscopy
1 year of ageSubstitute formula-DRACMA guidelines
Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA)
Symptoms or 1st formula 2nd formula 3rd formula
allergic disorder recommendation recommendation recommendation
IgE Extensively Amino acid Soy
low risk of hydrolyzed based
anaphylaxis
IgE Amino acid Extensively Soy
high risk of based hydrolyzed
anaphylaxis
FPIES Extensively Amino acid Soy
hydrolyzed based
Proctocolitis Extensively Amino acid
hydrolyzed based
EoE Amino acid ------- -------
based
J Pediatr Gastroenterol Nutr. 2012 A. Nowak-Węgrzyn, M. Chehade, M. Groetch, et al.
Aug;55(2):221-9 Journal of Allergy and Clinical Immunology 2017
Mount Sinai 2017 WAO DRACMA Guidelines. JACI 2010 33
Dec;126(6):1119-28The best formula to choose for Eve will be:
1) Amino acid based formula
2) Extensively hydrolysed formula
3) Any commercially available milk
4) A lactose free milk
34Level of avoidance required
IgE mediated FPIES Other non-IgE Mild-moderate EGIDS (EoE)
food allergies food allergies
Breast feeding Maternal No need for Maternal Maternal Unsure if
avoidance may maternal avoidance may avoidance may maternal
be required avoidance be required be required in avoidance
exclusively required – often
breastfed infants presents later in
infancy
35Level of avoidance required
IgE mediated FPIES Other non-IgE Mild-moderate EGIDS (EoE)
food allergies food allergies
Dietary intake Varies: Complete Varies: Varies: - Complete
- Complete avoidance - Complete - Complete avoidance
avoidance required avoidance avoidance required
including - No need to including required - Unsure if
“traces” avoid “traces” “traces” - No need to “traces” should
- Tolerance to - Tolerance to avoid “traces” be avoided
small small - Tolerance to - Unsure of
amounts amounts small small
- Tolerance to - Tolerance to amounts amounts of
baked foods baked foods - Tolerance to allergens are
baked foods tolerated
- Unsure if
Dietary management of peanut and tree nut allergy: what exactly should patients avoid? Turner et al. 2015 baked foods
are tolerated
36IMAP ladder Mild-moderate non-IgE mediated CMA Venter et al. 2017 37
Other Special considerations 01 02 03 Nut avoidance Fish/Shellfish Role of OAS in single vs. all avoidance EoE nuts
The similarities
between IgE and
non-IgE mediated
food allergies
39Which factors are affects in all types of food
allergies?
1) Feeding, nutrition, growth, quality of life
2) Spesific IgE testing is required for the initial diagnosis
3) Food avoidance has no effect on nutrition and long term food
preferences
4) There is no need for a referral to a dietitian
40Common nutritional
characteristics of children
with IgE and non-IgE
mediated food allergies
- Nutritional deficiencies
- Growth
- Feeding skills
- Short and long term effects on overall food intake
- Quality of life
Meyer and Venter et al. 2013
Sova et al. 2013
Meyer et al. 2015
Maslin et al. 2016
Venter et al. 2015 41What do mothers want?
Helps me to protect my child and keep them healthy
And when she says well actually she's getting enough from her fruit, she's getting enough from her veg, actually that's
okay...I get reassurance.”
Teaches me to be an expert
“It was really nice to say get information from her about the chocolate factories...which has then helped [child] with his,
his nut allergy.”
Provides me with hints and tips to provide some sort of normality
“I sort of think you've got to manage it, you know, for the children to have a proper, a rounded life...it's a sort of
balancing act all the time and um, it's about being realistic isn't it?”
Helps to promote my child’s independence
“...they give you that little biscuit, and this was just at the age where she wanted to challenge me with things…”
Advocates and helping me fight my child’s corner
Provides me with emotional support
“I found, I think one thing [the dietitian] really sort of made me think was „don't stress about it‟ which I thought was really
good because...He's just stopped eating everything other than what he wants to eat which is very minimal, so I, and I
think that's nice with [the dietitian] saying „just try a little bit of that, try a little bit of this, don't force it‟...and so, now I'm
just thinking don't worry about it.” (Lucy, son age 7)
Venter et al. Pediatr Allergy Immunol. 2015;26:126-32.
Mackenzie, Grundy, Glasbey, Dean, & Venter. Ann Allergy Asthma Immunol. 2015; 114:23-9Figure 1: Factors to take into account when developing
a patient specific exclusion diet
What does your allergy dietitian
consider when developing an
individualized avoidance strategy?
Industry and Environment
Foods to avoid and • Traveling and immigration
• Food and nutrition literacy
degree of avoidance • Threshold levels and cross contact /
contamination
• Safe eating away from home
Suitable substitutes
Nutrition
• Promote optimal growth
Self-management skills • Prevent nutrient deficiencies
• Development of normal feeding skills
• Optimal nutrition for long term health
Co-existing and
The Future
cross-reacting allergens
The role of nutrients, dietary patterns
and other factors in food on:
• Gut microbiome
Novel allergens • Immune system
• Allergy prevention and tolerance
development
Vetnter et al. 2018 43Thank you!
IgE mediated FPIES Other non- Mild – EoE
IgE moderate
non IgE
Diagnostic tests Y N N N N
Food challenge/reintroduction FC FC FC/FR FR FR
Avoid allergens- breastfeeding Y/N N Y/N Y (exclusively ?
breastfed)
Avoid traces Y/N N Y/N N ?
Tolerance of baked products Y ? Y Y ?
Affect nutritional intake Y Y Y Y Y
Affect nutritional status Y Y Y Y Y
Affect quality of life (different domains/aspects) Y Y Y Y Y
Parental need for dietary advice Y Y Y Y YThank you Rosan Meyer Neil Shah Trevor Brown Adam Fox Jo Walsh
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