Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants
Highlights: This clearly written, concise document communicates the essential details about a recent ground breaking study: Randomized trial of peanut consumption in infants at risk for peanut allergy which is the first randomized study investigating the timing of peanut introduction in infants at high risk of food allergy. Previous observational studies suggested that a delayed introduction may increase peanut allergy, and the results of this study strongly support that position. Infants with eczema or egg allergy (because they are a high risk for peanut allergy) were randomized to start peanut consumption around the time of weaning or delay consumption until 5 years. Peanut allergy (assessed at five years) was significantly lower in the groups that started peanut early. Peanut sensitization was measured prior to the study, and infants with a high degree of sensitization were excluded (because of increased likelihood of already being allergic). Note: this publication is the results of the LEAP study (Learning Early about Peanut Allergy).
Application to Dietetic Practice: The 2008 American Academy of Pediatrics recommendation suggests that high risk infants do not need to delay peanut. However, this new consensus recommends active peanut introduction for infants at high risk of allergy between 4 and 11 months. It also suggested that infants may benefit from evaluation by an allergist or physician trained in allergy prior to introduction. Unfortunately, many allergist have very long waiting lists. This leaves dietitians in a conundrum. Ideally, they should recommend families seek advice from a knowledgeable physician, but an appointment before the child is 11 months may not be likely. Therefore, dietitians can provide information on peanut introduction, but not specific recommendations.
Another good article on this ground breaking research is Preventing Peanut Allergy through Early Consumption — Ready for Prime Time? Pub Med ID – 25705823 Web Link
Original Study –Randomized trial of peanut consumption in infants at risk for peanut allergy – Pub Med ID 25705822 Web link
Highlights: When food allergic children attend school, the school staff and parents must work together to determine measures to keep the child safe. This article reviews the common, controversial issues that arise, such as the need for separate tables and allergen “free” classrooms. The importance of Anaphylaxis Action Plans and personnel training (and the lack in most schools) is summarized.
Application to Dietetic Practice: An objective discussion regarding these issues is provided and suggests that many measures such as separate tables and banning allergens from the classroom are unnecessary. This article may be beneficial for high literacy parents that are very concerned about the risks at school. The authors discuss the idea of proximity challenges in which the child is exposed (under medical supervision) to the allergen in similar proximity as they would at school (or other community settings). For example, the child sits next to someone opening a bag of peanuts. This may be very reassuring for parents and children that are anxious about potential exposure.
Pub Med ID: 25149169
Randomized clinical trial: gluten may cause depression in subjects with non-celiac gluten sensitivity – an exploratory study
Highlights: Twenty-two adult subjects with irritable bowel syndrome, but not celiac disease, that self-reported feeling better on a gluten-free diet randomly received snacks containing gluten, whey protein (one of type of milk protein) or placebo. Significantly higher levels of depression were reported after three days consuming a gluten containing snack compared with placebo or whey protein, even though there was no difference in gastrointestinal symptoms.
Application to Dietetic Practice: The concept that gluten may directly and very quickly influence mood is popular in the lay media, but has only recently received research attention. Larger studies are needed to further investigate these findings. The media suggests that gluten directly causes depression. However, depression may be a side effect of increased physical discomfort and reduced relaxation/sleep.
Pub Med ID: 24689456
Cognitive impairment in coeliac disease improves on a gluten-free diet and correlates with histological and serological indices of disease severity
Highlights: Eleven adult patients that recently started a gluten-free diet after celiac disease diagnosis were followed over one year – including histology (upper GI biopsy results), serology (blood tTG antibody), serum micronutrients and cognitive function measurements. Cognitive function was impaired at the beginning of the study, but all cognitive function measurements improved over the year (several of the measurements showed statistically significant improvement). Cognitive improvement correlated with histology and serology improvement, but not serum micronutrients.
Application to Dietetic Practice: Celiac patients often complain of brain fog prior to treatment with a gluten-free diet. This pilot study provides preliminary support for this manifestation and potentially demonstrates the importance of a gluten-free diet. When counselling celiac clients on the importance of following a strict gluten-free diet, improved cognitive function can be discussed (particularly for clients that report cognitive impairment). The authors indicate that additional, larger studies are planned on this topic.
Pub Med ID: 24889390
Highlights: An excellent overview of food allergens in medications is provide by this continuing medical education article (1 credit) from the American Academy of Allergy, Asthma & Immunology. Food allergens may be a component of the medication recipients. With a few exceptions, the risk to food allergic patients is minimal.
Application to Dietetic Practice: This would be an interesting article for dietitians working with IgE mediated allergic clients. Dietitians usually don’t advise clients on medication, but it is helpful to have an understanding of this topic. The dietitian could forward this article to the client’s pharmacist.
Pub Med ID: 24878443
Highlights: Allergic contact dermatitis is a rash that occurs when an allergen touches the skin. Examples include: lotions, cosmetics, soaps, fragrances, metals, etc. The specific allergenic compound can often be identified through patch testing (physician puts a suspected compound on the skin, patches it and assesses the skin after a few days). Many of these compounds are also found in food (e.g. nickel, balsm of peru). The article authors suggest a trial elimination diet, for patients that do not have satisfactory relief from eliminating topical exposure to the allergen. References are given for dietary guidelines.
Application to Dietetic Practice: The evidence for these elimination diets is based on case studies. To my knowledge, randomized clinical trials have not been done. However, being aware of this potential dietary trigger of contact dermatitis is important knowledge for dietitians working in food hypersensitivity.
Pub Med ID: 25149165
Highlights: A variety of elimination diets (elemental, six food elimination (empiric elimination) have been studied for the treatment of eosinophilic esophagitis. This article summarizes the evidence for each and provides two tables with practical dietary guideline s that are used in the authors’ clinic. The importance of a registered dietitian in nutritional assessment and education is stressed.
Application to Dietetic Practice: This would be an excellent article to forward to physicians who are reluctant to include diet in the treatment of eosinophilic esophagitis.
Pub Med ID: 24920928
Highlights: An expert group of allergy specialist dietitians developed a food allergy assessment form that can be used by physicians or other health care professionals when assessing pediatric or adult food allergy patients (see link below for assessment forms). The article gives detailed information on how to complete and interpret each section of the form.
Application to Dietetic Practice: All dietitians working with food allergy patients would benefit from reading this article.
Pub Med ID – 25741437, Web Link
»Allergy Focused Diet History – paediatric
Highlights: In the last few years, there have been fascinating advances in understanding how food components may adversely impact the gastrointestinal tract. These advances are discussed in the context of nonceliac gluten sensitivity.
Application to Dietetic Practice: Dietitians with a strong interest in food hypersensitivity and a good understanding of immunology will likely enjoy reading this article.
Pub Med ID – 25583468
Food allergy competencies of dietitians in the United Kingdom, Australia and United States of America
Highlights: A survey was conducted for dietitians in the above mentioned countries regarding their food hypersensitivity competencies and need for further training. A greater percentage of UK and Australian dietitians were exposed to food allergy education in their basic training compared to American dietitians.
Application to Dietetic Practice: This article would be valuable guidance for individuals or organizations that are designing food hypersensitivity education programs for dietitians. It also highlights the need for additional undergraduate training in the United States.
Pub Med ID – 25905007; Web link
Highlights: Mothers who had seen dietitians in an allergy clinic after their child was diagnosed with an immediate food allergy participated in a focus group about the service they received. In addition to the provision of typical information, the mothers appreciated the emotional support.
Application to Dietetic Practice: Pediatric dietitians providing food allergy counselling would benefit from reading this article. It is encouraging that dietetic services were so helpful to the mothers. This demonstrates the need for dietitians to be integrated into allergy clinics. This study was completed in the United Kingdom where there are more allergy specialist dietitians compared to Canada and the United States.
Pub Med ID – 25454014
Highlights: Parents that had previously seen a dietitian in a pediatric gastroenterology clinic for elimination diet counselling completed a three day food record. The aim was to see if the children were consuming micronutrient supplements to compensate for insufficient dietary intakes. The findings did not support this. However, this study reported what supplements the clients were taking, which may not be what the dietitian recommended. The authors speculated that this may have resulted from inadequate appointment time for the dietitian to thoroughly assess the client’s intake and provide accurate recommendations. They suggest that a multivitamin and mineral supplement should be routinely recommended.
Application to Dietetic Practice: Dietitians may want to consider routinely recommending a multivitamin and mineral supplement to all pediatric (and possibly adult) clients that are on elimination diets.
Pub Med ID – 25780558; Web link
Small amounts of gluten in subjects with suspected nonceliac gluten sensitivity: a randomized, double-blind, placebo-controlled, cross-over trial
Highlights: Subjects with nonceliac gluten sensitivity (based on self-reported symptoms with gluten ingestion) followed a gluten-free diet and were randomized to receive capsules containing gluten or rice starch for one week and then the opposite for separate week (cross over trial). A significant increase in symptoms while taking gluten was reported compared with rice starch. However, the symptom scores for individual subjects (Figure 3) show a different picture. Only about 5% met the criteria to confirm nonceliac gluten sensitivity (overall symptom score during gluten ingestion that was two standard deviations above rice starch symptom score).
Application to Dietetic Practice: The abstract suggests strong support for nonceliac gluten sensitivity, but the authors provide further information and a different perspective in the body of the article. This highlights the importance of reading the entire article and not just the abstract.
Pub Med ID – 25701700
Highlights: In the last few years, many pediatric allergist have started to assess children with milk or egg anaphylaxis to see if they tolerate the allergen if it is baked. The majority of patients do and are advised to include the baked allergen in their diet. This article reviews the evidence and provides much needed practical client instructions.
Application to Dietetic Practice: Essential reading for all dietitians that counsel pediatric food allergy clients.
Pub Med ID – 25577613
Description: The LEAP study has recently received a lot of media attention (see Preventing Peanut Allergy ….. in the research section). This article would be a great resource for clients that have questions about this study.
Target Audience: general public
Organization: Allergic Living Magazine
Description: Seriously Celiac is a website campaign to raise awareness about the genetic connection in celiac disease. Celiac patients are encouraged to talk with family members about the need for celiac disease screening. Tips on how to approach family members are provided through a well written practical guide and webinar. For family members that have not been tested, a guide with suggestions on how to talk with your doctor about screening is provided.
Target Audience: general public
Organization: National Foundation for Celiac Awareness
Description: Current, essential information to commonly asked questions about IgE mediated (immediate) food allergy is provided in an eye catching layout. It’s a good review for dietitians as well!
Target Audience: general public
Organization: Allergic Living Magazine
Your Clinical Questions
Recent studies have shown that approximately 75% of children with immediate allergy to egg or milk will tolerate these allergens if they are baked for long periods of time (e.g. muffins). Baking changes the nature and structure of some of the allergenic proteins thus increasing their tolerance. Milk contains several allergenic proteins. Some proteins break down when heated. Secondly, milk and egg proteins coagulate with other ingredients as they bake. These two factors may change the proteins enough that the immune system no longer recognizes them. See Baked Milk and Egg…in the research section.
Oral allergy syndrome (also called pollen-food syndrome) may affect patients who are allergic to inhaled plant pollens (e.g. hay fever or seasonal allergies). The patient’s immune system reacts to a specific protein in the plant pollen. If certain fruits or vegetables contain a similar protein, the patient may experience tingling in the mouth when eating the raw fruit or vegetable (plant proteins usually break down with heat). Reacting to more than one substance because they contain similar proteins is called cross reactivity. There are many lists that indicate what fruit or vegetables cross react with each plant pollen, but these lists are variable and there is likely geographical variation. Future research may show that cross reactivity goes far beyond the current understanding of oral allergy syndrome.