PAEDIATRIC
Mary Feeney Paediatric Allergy Dietitian, King’s College London Mary has worked as the FASG Project Dietitian funded by a joint grant from the BDA GET and Anaphylaxis Campaign to develop guidance and dietetic resources in three areas of food allergy management through evaluation of research literature, current practice and dietetic consensus. Mary is also a research dietitian and is currently working on the LEAP Trio Study.
REFERENCES Please visit the Subscriber zone at NHDmag.com
DEVELOPMENT OF HOME INTRODUCTION GUIDES FOR EGG, SOYA AND WHEAT IN NON-IgE-MEDIATED ALLERGY The need for consistent guidelines on the introduction of egg, soya and wheat in non-IgE-mediated allergy, has been much highlighted, so much so that a project has been supported by the BDA General and Education Trust Fund and the Anaphylaxis Campaign. Out of this has seen the development of home introduction guides specifically for non-IgE-mediated allergy in children. The diagnosis of food allergy can be difficult and is often delayed, particularly for non-IgE-mediated allergies where symptoms are gradual in onset and occur ≥2 hours after eating the causative food(s).1-2 This type of allergy often presents with symptoms that overlap with other common conditions of infancy and childhood, including colic, reflux, eczema, altered bowel habit or faltering growth, making the diagnosis of allergy more challenging.3 Delays with diagnosis can lead parents/caregivers who suspect food allergy to eliminate multiple foods from their child’s diet. Children can often continue on restricted diets for prolonged periods without a significant improvement in symptoms. Such restricted diets can be onerous to follow and may be of limited variety with consequences including risk of nutritional deficiencies, faltering growth and longer-term impacts on family life.4-6 In the absence of validated allergy tests, the diagnosis of non-IgE-mediated allergies relies on the use of an allergyfocused clinical history to identify the likelihood of an allergy and the food or foods which may be involved.7 The diagnosis is further refined through the strict avoidance of the suspected allergen(s) for a trial period followed by re-introduction. The dietitian facilitates diagnosis by educating parents/ caregivers about which foods to avoid and advising on suitable alternatives to expand the diet and achieve nutritional
needs. If symptoms clearly improve during the elimination period, this supports a diagnosis of likely non-IgEmediated allergy; however, this is only confirmed if symptoms reoccur following re-introduction of the allergen(s). If the re-introduction step does not occur, then there is a risk of continuing the elimination unnecessarily.3,8 The Milk Allergy in Primary Care Guideline (MAP), developed to support the diagnosis and management of mild to moderate non-IgE-mediated cow’s milk allergy, includes practical guidance for home re-introduction of cow’s milk. This guideline is now widely used across care settings and has recently been updated with an international group of collaborators.8,9 UK dietitians often advise on home introduction of other common allergens; such as egg, soya and wheat. However, there is currently no established guidance, which means that advice may be inconsistent. The Food Allergy Specialist Group (FASG) of the British Dietetic Association (BDA) has already published evidence-based diet sheets for use by BDA member dietitians to support patients with allergen avoidance.10 FASG members indicated that there was also a need for resources to support patients with allergen introduction/ re-introduction. The purpose of this project was to develop standardised home introduction guides for egg, soya and wheat based on current research literature and by dietetic-led consensus. www.NHDmag.com April 2018 - Issue 133
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FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies
THE FIRST AND ONLY EHF
TO CONTAIN GOS/FOS PREBIOTICS
Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to five years1–3
the
step st ep in the effective management of
cows’ milk allergy is extensively hydrolysed formula†
.-=-.__
••
Aptamil.
References: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the fi rst two years of life. J Nutr. 2008;138:1091-5. 2. Arslanoglu S et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the fi rst 5 years of life. J Biol Regul Homeost Agents. 2012;26:49-59. 3. Pampura AN et al. Ros Vestn Perinatol Paediat 2014;4:96-104
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. † For the management of mild to moderate IgE-moderated cows’ milk allergy the iMAP guideline recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.
18-044 (GOS/FOS)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018
Healthcare Professional Helpline: 0800
996 1234 www.eln.nutricia.co.uk/cma
THE PROJECT
Members of the FASG (n=350) were invited to submit copies of the resources they currently use to advise on home introduction of egg, soya and wheat. Information was received from nine centres (one private, four secondary care, four tertiary care). The project dietitian collated the information and together with feedback from project supervisors and experienced colleagues, developed draft standardised home introduction guides. Allergy dietitians (n=8) from a variety of clinical settings were then invited to contribute to forming a consensus based on the ‘Delphi’ technique.11 Five agreed to participate. The Delphi technique comprises of questionnaires answered anonymously by a panel of participants with relevant expertise. An advantage of this approach is that a participant’s decision to maintain or change their opinion during the process is unaffected by a desire to be seen to agree with certain other group members, e.g. seniors. The consensus questionnaire for the home introduction guides included questions related to the following debated areas: • Overall layout and content • Recommended portion sizes • Duration at each introduction stage • Assigning allergen foods to specific re-introduction stages • Appropriateness of recipes included • Advice about immediate allergic reactions • The disclaimer statement The areas of agreement and disagreement were identified and the resources revised until full consensus agreement was achieved. Of the debated areas, ≥60% of the group agreed with the draft introduction guides in five of the seven areas for the egg resource, in three of the seven areas for the soya resource and with five of six areas for the wheat resource. The highest levels of agreement related to the overall layout and content of the wheat resource. The highest levels of disagreement related to recommended portion sizes for soya-containing foods (80% considered them too large). The greatest levels of discordance within the group related to the recommended duration at each portion size and introduction stage. Primary
and secondary care dietitians preferred a slower progression, indicating that they typically advised patients to spend between three days to a few weeks at each stage before progressing to the next. Tertiary care dietitians preferred faster progression, typically advising patients that they could progress to the next introduction stage within days if they were non-symptomatic. This may reflect local variations in practice, or differences in the patient groups attending clinic in the different settings. In order to develop a resource which was considered suitable across all settings, the final versions of the introduction guides allow the dietitian to specify the number of days they recommend the patient spend at each portion and stage. There was discussion about the possible benefit of very slow progression in order to establish low levels of tolerance and whether maintaining tolerated intakes might support the acquisition of tolerance. Whilst there is some limited evidence for this approach in IgEmediated allergy to cow’s milk and egg, this has not been established for other foods, nor is there published evidence of a role in non-IgE-mediated allergy.13-14 However, even if gradual introduction of tolerated foods containing the allergen does not hasten tolerance acquisition, it can still have important benefits for the child and their family.14 USING THE HOME INTRODUCTION GUIDES
The guides are designated for use only in nonIgE-mediated allergy. This is due to concerns about the risk that individuals with an IgEmediated allergy could have a severe allergic reaction during allergen introduction.12 If used in the designated patient group, an immediate allergic reaction on introduction of the allergen food is considered very unlikely; a low initial portion size (half a teaspoon-size) has been included as a further safety step. It is recommended that those with IgE-mediated allergy should have had a negative oral food challenge in a clinical setting prior to continuing to consume the allergen food at home. Allergen foods were categorised into introduction stages based on clinical/expert opinion. Allocation was based on the allergen protein content of the food, temperature and duration of heating, e.g. baking, pasteurisation, www.NHDmag.com April 2018 - Issue 133
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PAEDIATRIC
Development of home introduction guides for egg, soya and wheat in non-IgE-mediated allergy *Table 1: Egg-containing food categories included in the egg home introduction guide Baked/well-cooked Plain, shop-bought cakes (avoid royal or fondant icing)
Loosely/lightly cooked (yolk and white cooked solid) Homemade pancakes
Biscuits, e.g. Jaffa cake, sponge fingers, cookies, TUC crackers
Boiled, fried, scrambled or poached egg - choose British Lion stamped eggs
Homemade cakes, biscuits and sponge puddings
Quiche, flan, Spanish tortilla, omelette
Shop-bought pancakes
Egg fried rice, Egg Fu Yung
Undercooked or raw Royal or fondant icing (fresh and powdered), homemade marzipan Some chocolates and sweets contain egg, e.g. nougat, MarsTM bars, Milky WayTM, ChewitsTM, chocolates with fondant/cream fillings, Cadbury Creme EggTM
Egg glaze on pastry
Raw egg in cake mix, other Dried egg noodles, fresh egg pasta uncooked dishes
Gluten-free bread with egg, e.g. GeniusTM, LivwellTM, WarbutonsTM
Fish, meat or vegetables fried in egg-based batter or tempura
Brioche, Cholla, choux pastry, rich shortcrust pastry with egg
Egg in batter or bread crumbs, e.g. Scotch egg
Dried egg pasta, e.g. lasagne, cooked for at least 10 minutes
Yorkshire puddings with soft centres, e.g. sticky batter
Some gravy granules contain egg, e.g. chicken flavoured gravy
Crème Brulee, egg custard, fresh custard
Shop-bought Yorkshire puddings, must be pre-cooked, e.g. frozen
Meringues - well-cooked with no sticky centres
Sausages containing egg (vegetarian and meat varieties), other processed meats, e.g. burgers
Some marshmallows
QuornTM-based products
Lemon curd
Fresh mayonnaise, Horseradish sauce, Tartare sauce, Béarnaise, Hollandaise sauce, mayonnaise, salad cream Cheeses containing egg lysozyme (E1105), e.g. Grana Padano, Manchego Meringues with sticky centres, soft meringue, e.g. lemon meringue pie Some ice-creams and sorbets, especially fresh and luxury types, e.g. Ben and Jerry’sTM, HäagenDazsTM Some mousses (most shop-bought mousses do not contain egg)
Table adapted from BSACI guidelines on management of egg allergy 2010 and updated by dietitian consensus 2018.
*Table 2: Recipes containing baked soya included in the home introduction guide for soya Savoury muffins (makes 6) 250g flour or wheat free flour mix 2 ½ teaspoons baking powder 50ml vegetable oil 250ml soya milk 60g soya cheese, grated/sliced Handful spinach (optional)
Method Preheat the oven to 180°C/Gas Mark 4 and line a muffin tin with 6 cases. Mix the flour and baking powder. Mix the oil and soya milk together and add to the dry ingredients. Add the soya cheese and chopped spinach if desired. Loosen the mix with extra soya milk if needed. Bake for 15-20 minutes until golden. Cool on a wire rack. (~1.8g soya protein per muffin)
Veggie Bolognese (4 portions) ½ tablespoon vegetable oil 150g soya mince ½ a small onion, chopped 1 small carrot, diced ½ clove of garlic, crushed 75ml vegetable stock ½ tin chopped tomatoes 2 tsp soya sauce Seasoning
Method Heat the oil in a non-stick pan and cook the onion and carrot for 5 minutes. Add the garlic and cook for a further minute. Add the soya mince, stock, tinned tomatoes, soya sauce and season with salt and pepper. Bring to the boil, reduce the heat and simmer for 15 minutes. Serve with cooked pasta. (4.8g soya protein per portion)
PAEDIATRIC matrix effects of wheat (for egg and soya) and other manufacturing processes which may impact on allergenicity, such as fermentation of soy products. Although these factors have predominantly been investigated in the context of IgE-mediated allergy; clinical expertise suggests that this may also be a pragmatic and safe approach for use in non-IgE-mediated allergy. The egg ‘ladder’15 has been modified following changes in the egg content of products currently available, e.g. many brands of dried noodles no longer contain egg and from updated manufacturers’ information about product preparation and processing (see Table 1*). It was agreed by dietitian consensus to move some products to a different group where it was viewed that patients might be unable to safely judge differences in very similar products, e.g. commercial mayonnaises containing pasteurised egg, or fresh mayonnaise containing raw egg. There are some products for which there is limited information available as to their exact preparation due to manufacturers preferring not to disclose such details. A decision was taken to categorise such products in the same group as similar products for which manufacturing information is known, e.g. nougat is made by pouring hot sugar, honey, or liquid glucose (120-150oC) over raw egg white which is then mixed and left to cool. As the heating of the raw egg is for a short duration, it has been included in the group ‘undercooked or raw egg’. Confectionary items with similar ingredients have also been included in this group, e.g. Milky WayTM, MarsTM bar. The rationale for including baked egg or soya in a flour matrix relates to research which found that heating of cow’s milk or egg proteins in the presence of wheat results in decreased allergenicity, compared with heating alone.16-17 This may be due to these allergens forming complexes with wheat, such that the milk and egg proteins are less ‘available’ to the immune system. In vitro research supports that heating also reduces allergenicity of soy.18 Soya lecithin is widely used as an emulsifier in foods including crisps, chocolate, crackers and gravy granules. Although tolerated by most individuals with soya allergy, as the majority of the protein content is removed during the 28
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manufacturing process, some families do report allergic symptoms. It is included as the first stage in the soya introduction guide; however, if the dietitian is able to establish that the child is already eating and tolerating foods containing soya lecithin, they can start the introduction process at stage 2: baked soya in a flour matrix. Fermented foods containing soya are included as stage 3 in the introduction guide. There is research which indicates that the various fermentation processes used in the making of soya sauce and other fermented foods, such as miso or natto, leads to the degradation of some soybean allergens.19-20 Since there is a wide variation in recipes and preparation methods, e.g. duration of fermentation, the recommended portion sizes are small for the foods with a higher soya protein content. It is acknowledged that introduction of fermented soya products may be unsuitable for some individuals because of unfamiliarity with these foods, food preferences, as well as concerns about the typically high salt content of these foods. The inclusion of this stage should be discussed with individual families. It was not possible to accurately calculate the allergen protein content of many foods due to manufacturers preferring not to disclose such details and the fact that some foods contain more than one ingredient which contributes to the total protein content. The recommended target portion sizes, therefore, try to achieve a balance between portions with a broadly similar allergen protein content and those considered close to age-appropriate portions for young children. The approximate allergen protein content has been indicated per portion in the recipes, as this is more easily estimated (see Table 2*). CONCLUSION
Standardised home introduction guides for egg, soya and wheat in non-IgE-mediated allergy have now been developed by dietitian-led consensus. These resources support the provision of consistent dietetic advice on allergen introduction and improved outcomes for allergy patients and their families. Login to the BDA website to view the diet sheets and guides: www.bda.uk.com/ regionsgroups/groups/foodallergy/diet_sheets. They are available to all BDA members.