Management of food allergy: Nutritional issues
- Marion Groetch, MS, RD, CDN
Marion Groetch, MS, RD, CDN
- Director of Nutrition Services
- Jaffe Food Allergy Institute
- Icahn School of Medicine at Mount Sinai
The goals of nutritional intervention in patients with food allergy are twofold: prevent acute and chronic food allergic reactions through allergen elimination and ensure optimal nutrition within the context of the allergen-restricted diet.
Nutritional management of food allergy requires careful planning to ensure that the nutrients inherent in the eliminated food(s) are adequately replaced. Nutrient-dense alternative food sources should be recommended when elimination diets are initiated. Follow-up to ensure that the alternative nutrient sources have been accepted and incorporated into the diet is also recommended.
This topic will focus on the prevention of nutritional problems that can arise with food elimination diets. Food allergen avoidance is discussed separately. (See "Management of food allergy: Avoidance" and "Patient education: Food allergy treatment and avoidance (Beyond the Basics)".)
The indications for nutritional assessment, clinical features of nutrition disorders, measurements of growth, and laboratory evaluation of nutritional status are also discussed separately. (See "Indications for nutritional assessment in childhood" and "Measurement of growth in children" and "Laboratory and radiologic evaluation of nutritional status in children" and "Dietary assessment in adults".)
GENERAL NUTRITION AND FOOD ALLERGY
Dietary limitations secondary to food allergy can lead to failure to thrive and/or deficiencies in specific macro and micronutrients. Several studies have demonstrated that children with food allergies have lower intakes of total energy and macro/micronutrients than children without food allergy [1,2]. (See "Failure to thrive (undernutrition) in children younger than two years: Management" and "Poor weight gain in children older than two years of age" and "Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation", section on 'Etiology'.)
- Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J Am Diet Assoc 2002; 102:1648.
- Henriksen C, Eggesbø M, Halvorsen R, Botten G. Nutrient intake among two-year-old children on cows' milk-restricted diets. Acta Paediatr 2000; 89:272.
- NIAID-Sponsored Expert Panel, Boyce JA, Assa'ad A, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126:S1.
- Sampson HA, Aceves S, Bock SA, et al. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol 2014; 134:1016.
- Groetch M, Henry M, Feuling MB, Kim J. Guidance for the nutrition management of gastrointestinal allergy in pediatrics. J Allergy Clin Immunol Pract 2013; 1:323.
- Santangelo CM, McCloud E. Nutritional management of children who have food allergies and eosinophilic esophagitis. Immunol Allergy Clin North Am 2009; 29:77.
- Chehade M, Sampson HA. Epidemiology and etiology of eosinophilic esophagitis. Gastrointest Endosc Clin N Am 2008; 18:33.
- Mofidi S. Nutritional management of pediatric food hypersensitivity. Pediatrics 2003; 111:1645.
- Trumbo P, Schlicker S, Yates AA, et al. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. J Am Diet Assoc 2002; 102:1621.
- Liu T, Howard RM, Mancini AJ, et al. Kwashiorkor in the United States: fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol 2001; 137:630.
- Isolauri E, Sütas Y, Salo MK, et al. Elimination diet in cow's milk allergy: risk for impaired growth in young children. J Pediatr 1998; 132:1004.
- Jensen VB, Jørgensen IM, Rasmussen KB, et al. Bone mineral status in children with cow milk allergy. Pediatr Allergy Immunol 2004; 15:562.
- Agency for Healthcare Research and Quality. Effects of omega-3 fatty acids on lipids and glycemic control in type II diabetes and the metabolic syndrome and on inflammatory bowel disease, rheumatoid arthritis, renal disease, systemic lupus erythmatosus, and osteoporosis. Evidence Report/Technology Assessment no. 89 (Prepared by Southern California/RAND Evidence-based Practise Center, under contract no. 290-02-0003). AHRQ publication no. 04-E012-2, Rockville, MD March 2004.
- James MJ, Gibson RA, Cleland LG. Dietary polyunsaturated fatty acids and inflammatory mediator production. Am J Clin Nutr 2000; 71:343S.
- Dietary Reference Intakes (DRI) tables. http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&topic_id=1342&level3_id=5140 (Accessed on September 24, 2010).
- Mehta H, Ramesh M, Feuille E, et al. Growth comparison in children with and without food allergies in 2 different demographic populations. J Pediatr 2014; 165:842.
- Beck C, Koplin J, Dharmage S, et al. Persistent Food Allergy and Food Allergy Coexistent with Eczema Is Associated with Reduced Growth in the First 4 Years of Life. J Allergy Clin Immunol Pract 2016; 4:248.
- Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11 2002; :1.
- Berry MJ, Adams J, Voutilainen H, et al. Impact of elimination diets on growth and nutritional status in children with multiple food allergies. Pediatr Allergy Immunol 2015; 26:133.
- Berni Canani R, Leone L, D'Auria E, et al. The effects of dietary counseling on children with food allergy: a prospective, multicenter intervention study. J Acad Nutr Diet 2014; 114:1432.
- Salman S, Christie L, Burks W, Mccabe-Sellers B. Dietary intakes of children with food allergies: comparison of the food guide pyramid and the recommended dietary allowances, 10th ed. J Allergy Clin Immunol 2002; 109:S214.
- Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics 2001; 107:E46.
- Noimark L, Cox HE. Nutritional problems related to food allergy in childhood. Pediatr Allergy Immunol 2008; 19:188.
- Yu JW, Pekeles G, Legault L, McCusker CT. Milk allergy and vitamin D deficiency rickets: a common disorder associated with an uncommon disease. Ann Allergy Asthma Immunol 2006; 96:615.
- Fox AT, Du Toit G, Lang A, Lack G. Food allergy as a risk factor for nutritional rickets. Pediatr Allergy Immunol 2004; 15:566.
- Sampson HA. Update on food allergy. J Allergy Clin Immunol 2004; 113:805.
- Sicherer SH, Sampson HA. 9. Food allergy. J Allergy Clin Immunol 2006; 117:S470.
- American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346.
- Mannion CA, Gray-Donald K, Johnson-Down L, Koski KG. Lactating women restricting milk are low on select nutrients. J Am Coll Nutr 2007; 26:149.
- Fiocchi A, Schünemann HJ, Brozek J, et al. Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report. J Allergy Clin Immunol 2010; 126:1119.
- Olafsdottir AS, Wagner KH, Thorsdottir I, Elmadfa I. Fat-soluble vitamins in the maternal diet, influence of cod liver oil supplementation and impact of the maternal diet on human milk composition. Ann Nutr Metab 2001; 45:265.
- Butte NF, Calloway DH. Evaluation of lactational performance of Navajo women. Am J Clin Nutr 1981; 34:2210.
- Vandenplas Y, De Greef E, Hauser B, Paradice Study Group. Safety and tolerance of a new extensively hydrolyzed rice protein-based formula in the management of infants with cow's milk protein allergy. Eur J Pediatr 2014; 173:1209.
- Vandenplas Y, De Greef E, Hauser B, et al. An extensively hydrolysed rice protein-based formula in the management of infants with cow's milk protein allergy: preliminary results after 1 month. Arch Dis Child 2014; 99:933.
- Koletzko S, Niggemann B, Arato A, et al. Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr 2012; 55:221.
- The European Food Standards Agency. Survey of total and inorganic arsenic in rice drinks. http://www.food.gov.uk/science/research/surveillance/fsisbranch2009/survey0209 (Accessed on March 19, 2014).
- Sicherer SH. Clinical implications of cross-reactive food allergens. J Allergy Clin Immunol 2001; 108:881.
- Taylor SL, Hefle SL, Bindslev-Jensen C, et al. Factors affecting the determination of threshold doses for allergenic foods: how much is too much? J Allergy Clin Immunol 2002; 109:24.
- Crevel RW, Kerkhoff MA, Koning MM. Allergenicity of refined vegetable oils. Food Chem Toxicol 2000; 38:385.
- GENERAL NUTRITION AND FOOD ALLERGY
- - Replacement
- MONITORING GROWTH
- FOOD ELIMINATION DIETS
- Cow's milk allergy
- - Breastfed infants
- - Formula-fed infants
- - Children >1 year old
- Wheat allergy
- Egg allergy
- Soybean allergy
- Peanut, tree nut, fish, and shellfish allergies
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS