Summer 2013

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Research Update


Growth and nutritional concerns in children with food allergy

Highlights: Inadequate growth is common in children with diagnosed food allergy. Several factors may contribute, including: reduced nutrient intake, decreased absorption (intestinal inflammation) and increased requirements due to a variety of inflammatory comorbid diseases (eczema, asthma, etc.). Very close growth and intake monitoring is essential with children on a restricted diet.

Application to Dietetic Practice: Most pediatric dietitians would find this article too basic for their own learning, but it would be an excellent article for student dietitians and pediatricians. Also, it could be used to remind physicians to refer to a dietitian when prescribing a restricted diet.

Pub Med Link

Misdiagnosed Food Allergy Resulting in Severe Malnutrition in an Infant

Highlights: This case study describes a 15 month old child that was admitted to the emergency department with significant malnutrition and infected skin lesions. The mother restricted the child’s diet due to perceived food allergies based on direction from the pediatrician and chiropractor. During the hospitalization to treat the malnutrition and skin lesions, all foods that had been restricted were successfully reintroduced.

Application to Dietetic Practice: Physicians may not recognize the potential consequences of unnecessary dietary restriction. This case study (and other published reports on the topic) can be used as a reference to encourage physicians to refer pediatric patient on restricted diets to a dietitian.

Pub Med Link

Childhood food allergies: current diagnosis, treatment, and management strategies.

Highlights:  Several food allergy consensus documents have been recently published. This article applies these guidelines to everyday practice. Table 2 describes eight clinical scenarios that general practitioners commonly encounter and appropriate interventions. The scenarios are applicable to dietitians as well. The fifth scenario states “All children with food allergy should be given epinephrine”. The reader should be aware that the authors are referring to IgE (immediate) allergy. Table 1 summarizes formula choice by clinical scenario. Table 4 from, Practical approach to nutrition and dietary intervention in pediatric food allergy (2013) is a more comprehensive reference, because it is based on DRACMA: Guidelines for the diagnosis and rationale against cow’s milk allergy (2010).

Application to Dietetic Practice: Pediatric dietitians would find this a useful article.

Pub Med ID #: 23639501

Experiencing a first food allergic reaction: a survey of parent and caregiver perspectives.

Highlights: Members of the Anaphylaxis Canada database were invited to participate in a survey and qualitative interviews about the education they received after the first reaction and along the continuum of care.  In brief summary, families often did not receive education from health care professionals after the first reaction. Most education was received at the allergist appointment which was often months after the first reaction. Anaphylaxis Canada will work toward having resources available earlier in the continuum of care.

Application to Dietetic Practice: Hospital dietitians should consider developing a package of information for their emergency departments to provide to clients that have been treated for food anaphylaxis. Excellent print and online resources exist, so additional resources do not need to be developed. The client can be directed to the best resources and invited to make an appointment with the dietitian if guidance with dietary restriction is needed.

Web Link

ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease

Highlights: The American College of Gastroenterology has developed clinical guidelines for the diagnosis and management of celiac disease. Forty-three recommendations are evaluated based on the GRADE system. Five recommendations pertain to the diagnosis among patients on a gluten-free diet. With gluten-free becoming the new “fad” diet, many patients are eliminating gluten without celiac disease testing. These recommendations will help dietitians advise clients about their options for testing.

Application to Dietetic Practice: This is a great reference for all dietitians that counsel clients regarding celiac disease or the gluten-free diet. The recommendations are summarized at the end of the document, for those that are time challenged.

Web Link

Resources Update


Gluten and Casein Free Diet for Autism Spectrum Disorder (Client Handout)

Description: Information on the possible benefits and drawbacks of the diet are objectively presented. The important role of the dietitian is also discussed. This information helps the reader decide for themselves if they want to try the diet, and encourages them to contact a dietitian if they do. It would be a great handout to provide to other health care professionals that see children with autism.

Target Audience: General Public

Organization: British Dietetic Association

Website Link

Baking Without Milk, Eggs, Soy, Wheat, Gluten and Nuts (Archived Webinar)

Description: Substitutions for milk, egg, wheat/gluten, corn and rice are clearly presented. This would be a good video for dietitians that counsel on these restrictions and for clients that avoid these allergens. For clients, avoiding only one allergen, a handout on that single allergen would be more appropriate. The presenter is Colette Martin, author of Learning to Bake Allergen-Free.

Target Audience: General Public

Organization: Kids with Food Allergies

Website Link:

Your Clinical Questions


What can I recommend as a butter/margarine substitute in baking for my clients that are allergic to milk and soy?

Butter or margarine needs to be replaced by another fat that is solid at room temperature. If it is replaced by liquid vegetable oil, the final product will have a different texture. It is important to clarify the client’s soy restriction. Many clients are able to consume soy oil and soy lecithin, because there is very little soy protein in these ingredients. The client’s physician may need to be contacted. If in doubt, restrict these ingredients.

Several options are listed below. With each, a 1:1 substitution can be used.

1) Shortening – most shortenings contain soy oil. If the client is avoiding soy oil, Spectrum Organic Shortening is made from 100% palm oil.

2) Coconut oil is widely available. It may give a slight coconut flavor, but that works well with most products.

3) Margarine – Milk-free margarine is available in most grocery stores. Fleishman’s Lactose free is one example. However, it contains soy oil and soy lecithin. If the client is avoiding these ingredients, Earth Balance Soy–Free spread is a good option.

Note: Clients that are avoiding minute quantities of their allergen must contact the company about cross contact. If a milk-free margarine is made on the same equipment as a regular margarine, the milk-free margarine may contain small amounts of milk protein. Some companies test each batch for milk proteins.

I get referrals for infants under two years with “cow’s milk protein intolerance”. What is this?

The term should be avoided. It has been used to describe a milk allergy, but can easily be confused with milk (lactose) intolerance. If a physician provides this diagnosis, contact him/her to clarify. Ideally, the diagnosis should be one of the conditions described in the Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel 2.1.3 Definitions of specific food-induced allergic conditions.