Should the FDA add sesame to the current list of food allergens?

biscuit-biscuits-close-up-71126Different opinions exist about adding sesame to the FDA food allergen list – we of course respect this – below is a summary of the prevalence of sesame allergy:

Only one study world-wide reported on challenge-proven sesame allergy. This is the Food Allergy and Intolerance Research Study (FAIR) from the Isle of Wight.

The FAIR Isle of Wight study involved four different cohorts:

  • a birth cohort born between 2001 and 2002 and assessed at 3 years and 10 years
  • a school cohort born between 1997 and 1998 and assessed at 6 years
  • a school cohort born between 1991 and 1992 and assessed at 11 years
  • a school cohort born between 1987 and 1988 and assessed at 15 years

Diagnosis in the FAIR Study was based on food challenge or a good clinical history plus a positive skin prick test (SPT). We published 4 relevant papers from this study, three of which included data on sesame prevalence. These are summarized in the table below.

Additional unpublished data on sesame prevalence from the fourth study covering the 1991-1992 and 1987-1988 school cohorts are also included in the table, denoted with an asterisk.

It is important to take into account that some children declined to undergo food challenges in these studies. Recruitment and retention rates (indicated in the table by % of cohort assessed) were much higher in the birth cohort at both 3 and 10 year of age than in the school cohorts.

Cohort Age assessed % of cohort assessed Food challenge/good clinical history with positive SPT (%) Reported prevalence (%) by Gupta et al. (2018) **
Birth cohort (born 2001-2002) 3 years 91.6 0.6 (5/891)1 0.22
Birth cohort (born 2001-2002) 10 years 85.3 0.73 (6/872)3 0.32
Cross-sectional school cohort  (born 1997 – 1998) 6 years 55.4 0.1% (1/798)4 0.32
Cross-sectional school cohort (born 1991-1992 ) 11 years 47.4 0% (0/775) – confirmed by a history of regular consumption or negative oral food challenges*5 0.12
Cross-sectional school cohort (born 1987-1988) 15 years 50.2 0% (0/757) – confirmed by a history of regular consumption or negative oral food challenges*5 0.12

Birth cohort (born 2001-2002) 10 years 85.3
*not in paper – taken from our unpublished data

** listed as a comparison to the Isle of Wight data despite clear descepancy in study designs.

Differences in prevalence of sesame allergy:

From this one study conducted on the Isle of Wight (UK) more than 17 years ago, it seems the reported prevalence for sesame allergy was higher in the younger cohort (0.7% for children born 2001 – 2002) than in the older cohort (0% for children born 1987 – 1988/1991-1992). This could indicate that sesame allergy prevalence might have increased. However, issues with recruitment and retention in the school cohort studies should also be taken into account  and could serve as another possible explanation for the difference in challenge-proven sesame allergy prevalence between cohorts.

The figures from the FAIR Isle of Wight school cohorts are also lower than the recent US prevalence estimates reported by Gupta et al. (2018).2Again, issues with recruitment for the school cohorts,  indicated in the table, should be taken into account. The sesame prevalence data from the FAIR birth cohort (2001-2002), are more recent and have higher recruitment/retention rates. This cohort reflects a 0.6 percent prevalence at 3 years and 0.7 percent prevalence at 10 years, both higher than the US prevalence estimates reported by Gupta et al.2

Carina Venter and Tara Dean

1. Venter C, Pereira B, Voigt K, et al. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy2008;63(3):354-9. doi: 10.1111/j.1398-9995.2007.01570.x

2. Gupta RS, Warren CM, Smith BM, et al. The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States.Pediatrics2018;142(6) doi: 10.1542/peds.2018-1235 [published Online First: 2018/11/21]

3. Venter C, Patil V, Grundy J, et al. Prevalence and cumulative incidence of food hypersensitivity in the first ten years of life. Pediatr Allergy Immunol2016 doi: 10.1111/pai.12564

4. Venter C, Pereira B, Grundy J, et al. Prevalence of sensitization reported and objectively assessed food hypersensitivity amongst six-year-old children: a population-based study. Pediatr Allergy Immunol2006;17(5):356-63. doi: 10.1111/j.1399-3038.2006.00428.x [published Online First: 2006/07/19]

5. Pereira B, Venter C, Grundy J, et al. Prevalence of sensitization to food allergens, reported adverse reaction to foods, food avoidance, and food hypersensitivity among teenagers. J Allergy Clin Immunol2005;116(4):884-92. doi: 10.1016/j.jaci.2005.05.047 [published Online First: 2005/10/08]

 

Travelling while following a six food exclusion diet…

During the time that I followed the six food exclusion diet, I also attended conferences, which included travelling in the US and Europe. It was not easy but totally doable.

 

Breakfast

American hotels

Breakfasts mainly consisted of oatmeal made with water, fruit/fruit salad and a suitable yogurt, which I packed in my checked bag. (Daiya Dairy-Free yogurts®, Living Harvest® Tempt Hemp Yogurt®). I never traveled without high protein, high fiber cereal bars (recipe) – these came in handy in one of the hotels where the oatmeal was prepared with milk.

One of the hardest things for me while following this diet was having to drink tea (thanks to living for almost 20 years in the UK) or coffee without a milk replacement. In the US however, many hotels have a Starbucks® in the foyer. I used to grab a coconut milk latte/cappuccino on my way to the breakfast room.

European hotels

Eating breakfast in European hotels was an interesting experience, which was easier in some hotels than others: Suitable foods included: fruit, “rice porridge” bacon, ham (of which I checked the ingredients), grilled tomato and steamed vegetables. I also prepacked suitable cereals in small containers (Arrowhead Mills® Puffed Rice, General Mills Corn ChexTM, Arrowhead Mills® Quinoa Rice) and travelled with ready-made high protein milk replacements from Orgain®.

For children I suggest to travel with a suitable high protein drink e.g. Orgain®., suitable sunflower seed butter or other suitable spreads (Sunbutter, Trader Joe’s Sunflower Butter, Harvestbetter Multigrain Spread, Once Again™ Tahini Spread) and crackers (Edward&Sons Brown Rice Snaps®, GimMe™ Seaweed Rice Chips , Goldbaum’s Quinoa Crisps and suitable corn chips). Fruit from the hotel should be suitable.

Lunch

American hotels and European hotels

Both the American and European hotels served green salads but I had to ask for a salad without any dressing on a number of occasions. I took suitable mayonnaise (NuCo Coconut Vegan Mayo®) with me when travelling but I preferred the olive oil and vinegar mix as a salad dressing.

Potato or rice were served at most meals and the hotels were happy to prepare chicken, beef or lamb without any sauces/gravies. Lunch mainly consistent of meat (of some form), salad (or steamed vegetables if available) and rice or potatoes (without any additions if available).

For children: Ask if they have carrot sticks, cherry tomatoes, slides cucumber or sweet corn as most young children, do not enjoy adult style salads. Fries may be an option if they use suitable oil and do not fry foods, other than the potato, in the same oil. In one of the hotels they offered to prepare rice noodles (Lundberg Brown Rice Pasta ®) that I took with me, covered it in a homemade tomato jus – most children should be happy with this option as well.

Dinner

American and European restaurants

Dinners in restaurants were very simple. I asked the chef to clean the grill as well as possible* or to cook chicken or beef in foil. I had a jacked potato on most occasions (without butter) with a fresh salad drizzled with olive oil and vinegar.

For children, I suggest the same strategy as lunchtime. My own experience, having traveled with my children from a young age, through many countries, is that dinner is not usually a good time for negotiations about food. Offering a high protein drink with a few bits of chopped vegetables and fruit may just save the day when dealing with a tired child.

 In flight

Flights were tricky and as the diet is so complex, I decided to take my own food. I packed a high protein powder from Orgain®, which I mixed with water on the airplane (the ready-made versions were not allowed through customs). I also took my own fruit and high protein cereal bars.

For children, and as a treat, melt some dark chocolate morsels from Enjoy life® on the high protein cereals bars. For a savory option and if the flight is not too long, take home-made hummus, home-made corn chips or try hard corn taco shells from California Tortilla®. Plain or ready salted chips and suitable cheese slices (e.g. Daiya cheese slices) (if allowed on the airplane) may be an option as well. The grab and go packs from Enjoy life foods saved me many times.

*the degree of restriction will depend on the advice given by the physician

All products listed were checked and suitable for the six food exclusion diet at the time of posting the information. I have not received any payment/honorarium/funding from any of the companies involved.

Practical Tips for implementing a six-food elimination diet (SFED)

Following a six-food exclusion diet (SFED), which involves avoiding all foods containing the six most common food allergens in the United States, can be challenging for families to implement. It is used to treat some food allergy conditions and eosinophilic gastrointestinal conditions, such as eosinophilic esophagitis.

As a dietitian and researcher who works with patients receiving this recommended treatment, I thought it would be insightful for me to experience what our patients go through, especially as we are currently doing a clinical trial investigating diets excluding one food (avoiding milk) vs. six foods (SFED – avoiding milk, egg, wheat, soy, nuts and seafood) for six weeks.

When cooking:

 Breakfast

IMG_7527Oatmeal

I am a fan of oatmeal (make sure to use the gluten free option), served with blue berries and Daiya® milk-free yogurt on the side.

Pancakes

Some mornings, I did alternate oatmeal with pancakes baked with Bob Red Mills® 1-to-1 flour mix, which substitutes directly and in the same amount as the wheat flour for whichever recipe you are using. I replaced the milk in a standard recipe with a suitable milk replacement (Living Harvest® Tempt Hempmilk, So Delicious® Coconut Milk, Good Karma™ Flaxmilk, Suzie’s® Quinoa milk Beverage) and used VeganEgg® as the egg replacer. Sometimes, in order to increase the protein content of the pancake, I replaced the egg with mashed banana and used a high-protein milk substitute.

High-protein milk substitutes

One of the few high-protein milk substitutes that I found that is free from all the allergens, including no mention of “may contain statements”, is the Orgain® range of products. I have successfully used these to make pancakes, cereal bars, high-protein milk shakes, cappuccinos, and lattes. They come in different flavors and also taste fine by themselves. It is an easy way to start the day whether you are dealing with a fussy eater or a child with food aversions.

 Lunch

Salads

I love salads and baked potatoes, but a balance of protein, carbohydrates, and fat is important for a healthy diet. Extra care is needed to make a SFED or any restricted diet a balanced diet. Sometimes I added rice or quinoa to the salad rather than eating the potato to get my carbohydrates. For protein, I usually added chicken or strips of steak. Ham or turkey slices are also an option for those who like them. Another quick but filling lunch was rice crackers with a salad and avocado.

I can suggest two different types of salad dressings:

  • mixing olive oil and vinegar
  • diluting Just Mayo® with a bit of water

Sandwiches

I am not much of a bread eater, but I did miss eating a sandwich! To solve this problem, I used Bob Redmills® bread mix and added the VeganEgg® to make SFED-friendly bread to use for sandwiches.

Dinners
Mexican

While following the SFED, I prepared Mexican meals often, using steak/chicken strips, corn tortillas, guacamole, and tomato/onion sauce, because it had a good balance of nutrients while still being flavorful.

Spaghetti bolognaise

My children adore spaghetti bolognaise. Preparing this dish with a wheat-free pasta and homemade tomato sauce allowed me to only have to make one meal – a huge bonus!
Staple meals
You could also prepare simple meals consisting of beef or chicken, rice or quinoa pasta or potato, and a salad and/or vegetable.

Personal Meal Substitution for a non-SFED Meal

Having a planned stand-by is incredibly helpful. When the rest of my family wanted to eat something that was difficult to substitute with all the necessary ingredients or when they were eating fish, I usually melted a suitable dairy-free cheese (Daiya® Provolone cheese) over corn tortillas and added a fresh green salad.

 Snacks on-the-go:

I often packed leftover quinoa pasta or rice pasta from the night before with a tomato-based sauce. I used nutritional yeast as a replacement for parmesan cheese on occasion. However, hummus (see recipe) with some vegetable sticks was my saving grace. I also often ate sunbutter as a dip for wheat-free cereal fingers (see recipe – a cereal bar cut long and slim like fingers rather than bars).CA9CA6CA-0225-458D-B353-8CC20256D3E7.jpg

 

The International Guidelines on Food Protein Induced Enterocolitis and the the driving force behind them

International Consensus Guidelines for the Diagnosis and Management of Food Protein-Induced Enterocolitis Syndrome (FPIES) were published recently in the Journal of Allergy and Clinical Immunology.

I have summarized the paper and highlighted the most important points in this blog.

As much as this paper was a mammoth task led by Anna Nowak-Wegrzyn and Matt Greenhawt, the driving force behind them was a mother, who “just wanted the best for her son”.  I am sure many of the co-authors will have interesting anecdotes of how and where they met Fallon – I for one was “recruited” as part of the iFPIES team, while  sneaking (dripping wet) late into a session on FPIES at the American Academy of Allergy, Asthma and Immunology annual meeting in Orlando 2008.

img_7494

Matt Greenhawt, Fallon Schultz, Anna Nowak, Alessandro Fiocchi

In Fallon’s words….

“The International Consensus Guidelines were truly born out of both passion and frustration. Passion to create change and eliminate the burdens faced by those affected, and frustration for the lack of clear direction and management of the disease. When my son was diagnosed six years ago, there was absolutely no information available on FPIES and this had serious implication on his quality of life and medical stability. I had to figure out how to keep him healthy, how to get him through traumatic and terrible reactions and how to feed him. I was a mother, who couldn’t feed my son. His story echoed the many families I found online, all of whom were managing FPIES on their own.

It was my dream to formalize an effective and applicable plan for every patient affected so that my son’s story was no longer the norm. One that would reflect the realities of FPIES and that would validate the symptoms and presentations us families all came to identify and know. When I approached the IFPIES Medical Advisory Board to take on this robust and difficult project, I knew it would take a great deal of time, patience and diligence. We were up against very little information and support in the medical community and often times, disbelief about the validity of this disorder. I felt a strong sense of responsibility to urgently advocate for our community and to ensure that future patients and families would never experience what those of us in the dark ages did. Each contributor was hand-selected for their expertise and more importantly, for their passion to create better pathways for their patients. They are a sincere, vocal and authentic group, all displaying compassion and empathy for their patients and practice.  I was touched by the heartfelt passion and mutual respect that these providers exhibited in each and every one of our meetings. I learned that it was not only the patients who were struggling with this bizarre food allergy, but the providers who were in the trenches, looking for answers and support for their patients. We learned from one another. It was a beautiful, collective, multi-cultural experience. In discussing the presentation in each cohort, we got clues about FPIES, we learned about different phenotypes and we took this information to create a 97 page document, marked forever in history as a jumping point for all those who have suffered the FPIES mystery.

I feel very blessed to have been any part of this monumental experience, to leave behind a legacy for future patients and providers and to lay groundwork in this disease. It is my great hope that patients and providers, worldwide, will benefit from this document and that we can take a giant leap forward to ensure a better quality of life and improved outcomes for all effected. It has been my honor to serve the FPIES community and to support the exceptional providers throughout this project.”

The International Food Protein Induced Enterocolitis Guidelines (FPIES) are out: what do they say?

 

 

Common myths regarding food allergy

I recently did a blog on common myths regarding food allergy with Dr David Fleischer, featured on the Asthma Allergies Children website.

 

Food Allergy Urban Myths: Two Experts Separate Fiction from Fact

Thanks to those that have helped to put our list together: Marion Groetch (USA), Berber Vlieg-Boerstra (The Netherlands), Rosan Meyer (France), Hannah Hunter (UK), Lianne Reeves (UK), Marianne Williams (UK), Paul Turner (UK), Isabel Skypala (UK), Fallon Schultz (USA), Raquel Durban (USA)

Weaning beyond peanut – part 2

Carina Venter and Rosan Meyer

Weaning: Points to take into account when introducing other allergens
allergens

This is a tricky topic. There are currently no specific guidelines on the introduction of allergens other than peanut. We base the following information on our own clinical experience; taking into account the NIAID guidelines. In order to explain introduction of the other allergens, let us revisit the groups identified by the NIAID guidelines:

Group 1: Infants with severe eczema, egg allergy or both.

Group 2: Infants with mild to moderate eczema.

Group 3: Infants with no eczema or food allergies

WE NEED TO EMPHASISE:

If your baby or child has any other type of food allergy other than peanut and egg, we suggest you consult your doctor before weaning onto other allergens/foods.

baby-1636317_640

Further reading: ASCIA guidelines for infant feeding and allergy prevention and EAACI food allergy and anaphylaxis guidelines: Primary prevention of food allergy

 

Weaning beyond peanut – part 1

Carina Venter and Rosan Meyerbaby-watermelon

The previous blog focused on the introduction of peanut in infants following the release of the NIAID guidelines. In the next two blogs blog, we would like to discuss the introduction of solid foods further.

Weaning: Points to take into account when introducing solid foods for ALL babies 

1. Importance of exposure to different tastes/flavor 

We have shown in some of our studies that avoiding milk from a baby’s diet with cow’s milk allergy, can lead to reduced likelihood of eating milk based foods even at 10 years of age. On the other hand, tastes and flavors that infants are exposed to, positively affect their preferences of those foods later in life. Infants are very good in distinguishing between different flavors and the more often they get exposure to a particular taste/flavor the more likely they are to eat that particular food – some foods needs to be given at least 15 times before the infant will happily eat it. The weaning period is therefore an ideal time to set the foundations for good eating habits.

2. Importance of exposure to different textures

Infants should be introduced to a variety of textures in early life ranging from purees, mashed, dissolvable and fingers foods. They should ideally tolerate the textures of family meals by 12 months, though some foods such as meat will need to be cut in smaller pieces.  Studies show that those infants, who have not eaten lumpy textures by 10 months of age, are more likely to develop faddy eating behavior in later childhood. Some mothers may prefer to do baby led weaning in which case you will offer your baby (age appropriate) foods that are soft-cooked and cut or mashed into small easily manageable pieces. This normally means that you will skip the phase of giving thin and runny purées and feeding your baby with a spoon. However, in terms of peanut, we suggest that you follow the recipes suggested by NIAID, included in our previous blog to prevent the risk of choking.

3. Importance of a varied or diverse diet 

A varied diet during infancy plays three important roles.

  • The more varied the foods introduced during the first few months of weaning, the less likely children are to have faddy eating behavior when they are toddlers.
  • A more varied diet will also positively influence nutrient intake.
  • Most importantly however, a more diverse diet, i.e. a diet with a large variety of different foods in the first year of life is also associated with the prevention of allergic disease, possibly via an effect on the infant’s microbiome.

4. Food preparation 

Food preparation and the use of home-made vs. commercial foods have recently been highlighted to play a possible role in the development of allergic disease. Commercial foods are sterile, the anti-oxidant content may be less than that of home-made foods and the variety can be reduced compared to home-cooked foods. This does however not mean that commercial baby foods cause food allergies, and home-cooking using lots of sugar and salt won’t benefit your baby either! Our common sense advice is: Cook/bake foods suitable for babies when you can, mash a banana or grate an apple when you can and use commercial foods in times when you are travelling or not at home.

See our next blog for guidance on introduction of other allergens.

Feeding your baby peanuts – Q&A

baby-eating
The new guidelines on “early” introduction of peanuts have received much attention in the past few days. For full background information and specific details, please read the guideline document. The information contained in this blog will serve as a practical guide for parents on introducing peanuts into the infants diet.

Weaning or introducing solid foods into your baby’s diet is meant to be a time of enjoyment, but with so much focus on allergen introduction, we risk “medicalizing” a process that should be part of normal development. I was very pleased to be invited as a member of the Expert Panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, to develop clinical guidelines on peanut allergy prevention.

The guidelines divide infants into 3 risk groups (guidelines 1, 2 and 3) and issued the following advice:

Group 1: Infants with severe eczema, egg allergy or both.

  • Check with your doctor before introducing peanuts at home.
  • Your doctor may recommend that your baby undergo allergy testing, followed by supervised peanut introduction if needed, before you introduce peanuts regularly at home.
  • Once you start giving peanut at home, it is recommended to give 2 g of peanut protein, 3 times per week.

Group 2: Infants with mild to moderate eczema.

  • Your doctor can tell you what “mild to moderate” eczema means and if it is safe for you to introduce peanut into you baby’s diet.
  • For this group of infant, the new guidelines suggest to start giving peanut around 6 months of age, after other solid foods have been tried.
  • Peanuts should be given based on the family’s eating preferences and given regularly to your baby.

Group 3: Infants with no eczema or food allergies

  • Start weaning your baby when developmentally ready.
  • Once a few foods are introduced, start giving your baby some peanut-containing foods.
  • Continue with regular peanut intake, based on the foods that your family likes and regularly eats.peanut-and-strawberries

Common questions:

  1. I thought peanuts can cause choking in children under 5 years of age, can I give it to my baby?

Yes – that is true – whole, shelled peanuts and lumps of peanut butter should not be given to children under 5 years of age due to the risk of choking; this is pretty much a recommendation all across the world. The new NIH guidelines recommend that you give your baby peanut puffs (e.g., Bamba), smooth peanut butter mixed with hot water and then cooled down, peanut flour, or peanut powder.

  1. Why 2g peanut protein, 3 times per week?

The amount of peanut used in the LEAP study was based on the median monthly consumption of 7.1 g peanut protein in Israeli children where peanut allergy prevalence is relatively low.

  1. What does 2 g of peanut look like, or is it actually 2 g of peanut protein?

It is 2 g of peanut protein. The NIH guidelines lists the following options for giving 2 g of peanut protein:

  • 17 g Bamba (another peanut puff that is very similar to Bamba is called Cheeky Monkey)
  • 9-10 g peanut butter depending on the brand
  • 8 g of ground peanuts
  • 4 g defatted peanut flour (e.g., defatted peanut flour from the Golden Peanut company) or peanut butter powder (e.g., PB2 powder or PB fit)
  1. I don’t have kitchen scales…does that matter?spoons

No – these amounts do not have to be that exact.

  • 17 g of peanut puffs is about 2/3 of a bag of Bamba.
  • 9-10 g peanut butter is either two level measured teaspoons or a “round full” teaspoon (Picture courtesy of myself and George Du Toit – the one and only LEAP first author)
  • 8 g of ground peanuts is 2 1/2 level measured teaspoons
  • 4 g of peanut flour or peanut butter powder is 2 level measured teaspoons
  1. What if my baby is sick and won’t eat, or if they are full and have not eaten the full portion?

We just do not know if smaller amounts or less frequent feeds will be as protective against the development of peanut allergy. However, according to LEAP authors, some of the babies got ill (as babies do) and some did not actually finish every feed, though most did. The main thing is to be as consistent as possible with regular peanut intake, even if your baby does not eat the full dose.

  1. What if my baby/child loves the peanut puffs and want to eat more?

peanut-puffsYes! Some babies are good eaters and love peanut flavor. Eating more is allowed; I also think that older children (peanut was given up to age of 5 years in LEAP) may not be happy if you remove the bag of Bamba once 2/3 of the bag is eaten. In the LEAP study, the median amount of peanut protein in the consumption group was 7.7 g (interquartile range, 6.7 to 8.8).

  1. I don’t think my baby will eat the peanut-containing foods in the NIH guidelines; is there anything else I can try?

I would say first try different options of the foods listed in the NIH guidelines. Peanut powder mixed with mango puree tastes very differently from diluted peanut butter mixed with baby rice or carrot puree. You could also try to crush the Bamba, dissolve it in water, and mix it into the baby’s pureed foods.
During the development of the NIH guidelines, we looked at other options, such as peanut-containing breakfast cereal or peanut containing candy (chocolate) and found that either the portion sizes would be too large (e.g., up to 6 cups of cereal) or the fat, sugar or salt content would be unsuitable for young children. If you are adventurous in the kitchen, try to bake low-sugar peanut cookies/biscuits – 1 cookie contains about 0.8 g of peanut protein, which means 2-3 cookies should give around 2 g of protein or cook peanut soup!

Any dietitian (irrespective of their knowledge of food allergy) can help you to find out what the peanut protein content of a food is by calculating it from the label (if peanut is the only ingredient) or from information obtained from the manufacturer. I am sure they will be happy to help ensure that you use foods that are culturally accepted and favorites of the family!

  1. Which solid foods are best to start with?

In terms of introduction of solid foods, just use the usual weaning advice as suggested by the country in which you live. In most situations, this will be vegetable or fruit purees or infant fortified cereal-rice/oat.

  1. Does it HAVE to be 4 months or 6 months?

I have mentioned in my introduction that weaning is part of normal development, and babies may be ready for solid foods at different ages; look out for developmental cues when starting to introduce solid foods – there is no need to set a clock to remind you that your baby is exactly 4 months of age! I absolutely love this fact sheet produced by colleagues of mine at the Infant and Toddler Forum.peanut-butter-sandwich

Some more easy recipes for peanut introduction in the first few years of life

 

The final knock out question:

My older child is peanut-allergic, I am not sure if it is safe to eat peanut around him?

This is a discussion that you have to have with your baby’s doctor, as many factors will determine how to approach the situation.

These guidelines address preventing peanut allergy and do not apply to anyone with diagnosed peanut allergy. Peanuts should not be given to those with peanut allergy – always follow your doctors advice.

Should all babies follow the NIAID guidelines for peanut intake – see my quick repose to this question 

How much fruit/vegetable puree or yogurt should be added to the peanut butter, peanut flour/powder or “Bamba-like” sticks/puffs?

Milk Allergies in Kids: Why You Should Actively Encourage Children With Milk Allergies To Have a Varied Intake of Tastes and Textures

It is known that young children with food allergies often exhibit ‘faddy’ or picking eating behaviour. In some presentations of food allergies, such as Eosinophilic Esophagitis, this may even present as a more severe form of faddy eating, referred to as feeding dysfunction.

I have often wondered if food exclusion diets during infancy still affect food intake years later, even into later childhood or adulthood. In 2012, I obtained UK funding for a PhD student to research the effect of cow’s milk avoidance in the first year of life on food choices up to a decade after any possible signs of cow’s milk allergy have resolved. The Food Allergy and Intolerance Research (FAIR) Cohort on the Isle of Wight were nearing 10/11 years of age and were ideal to perform such a study.

Kate Maslin RD led this research as part of her PhD and published the results earlier this year: Cows’ milk exclusion diet during infancy: Is there a long-term effect on children’s eating behaviour and food preferences?  She also set up collaborations with the team across the waters in Southampton who recruited a birth cohort (Prevalence in Food Allergy – PIFA) as part of the Europrevall study, and these children were nearing 5/6 years of age.

Kate showed that children who avoided cow’s milk for more than 4 months in the first year of life, rated their “liking” for dairy foods such as butter, cream, chocolate, full-fat milk and ice cream significantly lower than those who never avoided milk products. This was nearly a decade after the FAIR children outgrew any possible signs of milk allergy and up to 5 years after the PIFA children outgrew signs of a milk allergy.

What have I learned from this paper?

This paper has emphasised the importance of a dietetic consultation, focussing beyond just which foods should be avoided. Furthermore, I have realized that during dietary consultation the importance of focusing on suitable alternatives as well as what can be eaten is extremely important.

Looking at the particular foods the children did not “like” according the paper – butter, cream, chocolate, full-fat milk and ice cream – one cannot help question how often children ate any of the suitable milk-free alternatives based on soy, coconut, hemp, small amounts of rice and nut beverages (if tolerated) during the period of milk avoidance. If so, whether using these products would have prevented this long-term effect of less “liking”.

I therefore now spend significantly more time during consultations discussing suitable alternatives and ensuring the client’s diet is varied in terms of tastes and textures. Once the child outgrows their milk allergy, I stress the importance of introducing milk-containing foods as much as possible. This requires, in my opinion, very clear practical advice and at least one-two follow-up appointments with in RD.

Which questions still needs to be answered?

One of the questions our research team on the Isle of Wight particularly wanted to answer was if any particular formula(s) used for the diagnosis and management of cow’s milk allergy had a more profound effect on food intake than others. We unfortunately did not have the statistical power in each group to fully address this question.

Carina Venter PhD RD

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