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Nutrition Therapy for Pediatric
GastroenterologyPresented by:
Erin Helmick, RD
About Me
Graduated from MSU with Bachelor of Science in Dietetics
Completed dietetic internship at University of Michigan Health System
Employed as Registered Dietitian at Children’s Hospital of Michigan since 2006
5 years experience providing nutritional care for inpatients in acute care from newborn to 18 years old
Outpatient pediatric GI since 2011
Nutrition Therapy for GI Disorders Multiple Food Protein Allergies
Cow’s milk protein allergy
Food Protein Induced Enterocolitis Syndrome
Eosinophilic Esophagitis
Inflammatory Bowel Disease
Celiac Disease
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Objectives
Describe pediatric gastrointestinal conditions
Identify nutritional risks associated with these conditions
Discuss nutritional management
Food Allergy Defined
“An adverse health affect arising from a specific immune response that occurs reproducibly following exposure to a given food”
Boyce JA, Assa’ad A, Burks AW, 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:S1-58.
IgE Mediated vs. Non-IgE Mediated Food Allergies
IgE Mediated Antibodies called
Immunoglobulin E (IgE) are produced
Reaction is immediate
Usually involves respiratory symptoms and/or immediate nausea, vomiting, or diarrhea
Can be diagnosed by blood test and/or skin testing
Non-IgE Mediated
Do not involve IgE
Delayed onset (hours to days after ingestion)
More difficult to diagnose
Symptoms often GI related
Atkins, D. American Partnership for Eosinophilic Disorders. What’s the difference between a food allergy and food intolerance?, 2013. http://apfed.org/drupal/drupal/sites/default/files/files/IgE%20vs%20nonIgE%20reactions.pdf. 27 February 2014.
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Food Allergies
Most often present in the first 2 years of life
According to Food Allergy Research and Education (FARE), the top eight allergens are milk, egg, crustacean shellfish, fish, peanuts, tree nuts, wheat, and soy
These eight allergens account for 90% of all food-allergic reactions
Most allergies, except nuts and seafood, are outgrown during childhood
About Food Allergies. FARE. 2014. 11 March 2014.
Nutrition Therapy for Food Allergies
Complete diet elimination of food protein(s)
Can result in very restricted diets, inadequate in macronutrients and/or micronutrients
Label reading can be challenging
Consider multivitamin with minerals
Food Allergen Labeling and Consumer Protection Act of 2004
Food labels are required to state clearly whether the food contains a "major food allergen."
Must identify any of eight allergenic foods: milk; eggs; fish; crustacean shellfish; tree nuts; peanuts; wheat; and soybeans.
Statements of food processing handling are not mandatory
Food Allergen Labeling and Consumer Protection Act of 2004 Questions and Answers. FDA. 18 July 2006. 27 February 2014.
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Ingredients: Corn, Whole Grain Wheat, Sugar, Whole Grain Rolled Oats, Brown Sugar, Rice, Vegetable Oil (Canola Or Sunflower Oil), Wheat Flour, Malted Barley Flour, Salt, Corn Syrup, Whey (From Milk), Wildflower Honey, Malted Corn And Barley Syrup, Caramel Color, Natural And Artificial Flavor, Annatto Extract (Color). Bht Added To Packaging Material To Preserve Product Freshness.Vitamins and Minerals: Reduced Iron, Niacinamide, Vitamin B6, Vitamin A Palmitate, Riboflavin (Vitamin B2), Thiamin Mononitrate (Vitamin B1), Zinc Oxide (Source Of Zinc), Folic Acid, Vitamin B12, Vitamin D.Contains : Wheat, Milk.
Example
Calcium and Vitamin D Needs
Recommended Dietary Allowance for Children
Calcium 1-3 years: 700 mg/day 4-8 years: 1000 mg/day 9-18 years: 1300 mg/day
Vitamin D 1-13 years: 600 IU/day
Calcium/vitamin D supplement may be needed if needs cannot be met through alternative foods
National Academy of Sciences. Institute of Medicine. Food and Nutrition Board. http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-tables
Alternative “Milks”
Important to include as source of calcium and vitamin D
Options: Soy milk
Rice milk
Almond milk
Coconut milk
Extensively hydrolyzed or amino acid based formula (i.e. Nutramigen, Elecare, or Neocate)
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Cow’s Milk Protein Allergy (CMPA)
Most common food allergy in infants and children less than 3 years of age
Affects 2-3% of the infant population
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: 221-229.
GI Symptoms of CMPA
Vomiting
Diarrhea +/- blood
Occult blood loss
Frequent regurgitation
Failure to thrive
Refusal to feed
Dysphagia
Colic
Constipation
Iron deficiency anemia
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: 221-229.
Other Symptoms of CMPA
Respiratory: wheezing, runny nose, chronic cough
Skin: hives, swelling of lips or eyelids, atopic eczema
General: anaphylaxis, food protein induced enterocolitis syndrome
Likeliness of CMPA increases when at least 2 organ systems are involved
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: 221-229.
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Diagnosis of CMPA
Blood serum for IgE or skin prick testing may be useful
According to the World Allergy Organization, “60% of milk allergic reactions are IgE mediated”
Atopy patch test not recommended at this time
Diagnostic elimination of cow’s milk
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: 221-229.
CMPA in Exclusively Breastfed Infant
Estimated to occur in 0.5-1% of exclusively breastfed infants
Infant reacts to small amounts of cow’s milk protein excreted in mom’s milk
Commonly present with blood in the stool but are well-appearing otherwise
The Academy of Breastfeeding Medicine. Allergic Proctocolitis in Exclusively Breastfed Infant. Breastfeeding Medicine. 2011;6:435-40.
CMPA in Exclusively Breastfed Infants
Initiate milk free diet in mother
Includes complete elimination of all dairy products such as milk, cheese, cream cheese, ice cream, yogurt, etc. as well as other foods with “hidden” milk ingredients
Proper diet education for mom is essential
The Academy of Breastfeeding Medicine. Allergic Proctocolitis in Exclusively Breastfed Infant. Breastfeeding Medicine. 2011;6:435-40.
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CMPA in Exclusively Breastfed Infants
Will see symptom improvement in 72-96 hrs in most cases
Wait 2-4 weeks before considering further diet elimination
Further diet elimination may include restriction of soy, egg, citrus, nuts, peanuts, wheat, corn, and/or chocolate
The Academy of Breastfeeding Medicine. Allergic Proctocolitis in Exclusively Breastfed Infant. Breastfeeding Medicine. 2011;6:435-40.
CMPA in Exclusively Breastfed Infants
Management of breastfed infants with severe symptoms Trial of therapeutic formula for up to 2 weeks while mother
transitions to milk free diet
Allows for child’s condition to stabilize while mother expresses milk
If symptoms reoccur when breast milk is reintroduced, further maternal diet restriction or use of therapeutic formula needs to be considered
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: 221-229.
CMPA in Formula Fed Infants
Eliminate cow’s milk based formula and supplementary foods containing cow’s milk protein
Soy based formula and other mammalian milks (i.e. goat’s milk, sheep’s milk) are not an ideal alternative
Common approaches to management: Start with extensively hydrolyzed infant formula If no improvement in 2 weeks, change to amino acid based
formula
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: 221-229.
Du Toit, G. Meyer, R. Shah, N. Heine, R. Thomson, M. Lack, G. Fox, A. Identifying and managing cow’s milk protein allergy. Arcj Dos Cjo;d Educ Pract Ed. 2010;95: 134-144.
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Infant Formulas for CMPAAmino acid basedExtensively hydrolyzed protein
Infant Foods and CMPA
Introduction of single ingredient infant foods at 6 months of age is encouraged
WIC approved infant cereals, fruits, and vegetables can be utilized
Parents still need to be educated to check ALL food labels for presence of milk protein
Infant must avoid all milk containing foods until advised by his/her doctor
Challenge with Cow’s Milk
Consider after at least 6 months on diet or at 9-12 months of age Patient should be asymptomatic
Should be demonstrating appropriate growth
Challenge in home setting vs. doctor’s office dependent on history of patient’s symptoms
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: 221-229.
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Failure of Challenge
Ideally RD is involved to assess child’s diet and recommend appropriate alternative
May still require extensively hydrolyzed or amino acid based formula beyond 1 year of age to meet nutritional needs
Continue elimination diet for 6-12 months before considering challenge again
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: 221-229.
Food Protein Induced Enterocolitis Syndrome (FPIES)
Food allergy affecting the GI tract
Most common in early infancy
Acute symptoms: profuse vomiting, diarrhea, and dehydration Leads to severe lethargy, changes in body temperature and
blood pressure
Chronic symptoms: weight loss, FTT
Food allergy testing is generally negative
Reaction to causative food is delayedNowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.
Triggers for FPIES
Cow’s milk or soy based infant formula
Reaction to proteins in breastmilk is less common
Solid foods: rice and oats are most common triggers
Other common triggers for solid foods: barley, poultry, peas, sweet potatoes, green beans, and squash
Nowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.
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Treatment for FPIES
Elimination of the offending protein(s)
Change to formula containing extensively hydrolyzed protein
“About 10-20% of infants may require amino acid based formula”
Introduce yellow fruits and vegetables at 6 months instead of cereal
Wait until >12 months of age to introduce grains, poultry, and legumes
Consider challenge with cow’s milk and/or soy after 12 months of age
Nowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.
Eosinophilic Esophagitis (EoE)
According to the 2011 EoE Updated Consensus Recommendations, “Eosinophilic Esophagitis represents a chronic, immune/antigen mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation”
Symptoms of EoE
Dysphagia
Feeding difficulty
Chest pain
GERD, non-responsive to medical and surgical treatment
Vomiting
Abdominal pain
Early satiety
Food impaction
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Treatment of EoE
Topical swallowed corticosteroids Fluticasone: puffed and swallowed via inhaler
Budesonide: taken as a viscous suspension
Diet management
Acid suppression
Esophageal dilation
Liacouras, CA, Furuta GT, Hirano I, et al. Eosinophilic Esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011;128:3-20.
Diet Therapy for EoE
Elemental diet
All food proteins removed from diet
Strict use of amino acid based formula
May require enteral feedings
Simple sugars, salt, and oils are allowed
Targeted elimination diet
Involves elimination of foods based on food allergy testing and history
Six food elimination diet
Involves elimination of six major food allergens
Milk, soy, wheat, tree nuts/peanuts, egg, fish/shellfishLiacouras, C. et. al. Eosinophilic Esophagitis: Updated Consensus Recommendations of Children and Adults. Journal of Allergy and Clinical Immunology. 2011;128:3-20.
Factors to Consider
Ability to manage complex diet
Potential nutritional risks
Access to amino acid based formula
Expected compliance
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Food Challenges
Usually managed by gastroenterologist and allergist
Repeat endoscopy(s) with biopsy may be performed to assess progress
Allergist may perform additional or repeat food allergy testing to identify ideal foods to introduce
One new food added at a time
Book, W. Leo, H. “Treatment of EGID’s.” American Partnership for Eosinophilic Disorders. 15 March 2013. Web. 5 March 2014.
Inflammatory Bowel Disease (IBD)
Crohn’s Disease Chronic inflammation of GI tract
Can affect any part of GI tract
Can affect entire thickness of bowel wall
Ulcerative Colitis Inflammation and ulceration of lining of colon
“What are Crohn’s and Colitis?” Crohn’s and Colitis Foundation of America. 2014. Web. 5 March 2014.
Epidemiology of IBD
According to the CDC, it is estimated that 1.4 million people in the United States suffer from IBD
Approximately 10% of these cases are individuals <18 years of age
Peak age of onset is 15-30 years
“Inflammatory Bowel Disease (IBD).” Centers for Disease Control and Prevention. n.p. Web. 14 January 2014.
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Inflammatory Bowel Disease
Micronutrient and macronutrient deficiencies are common in pediatrics
Result of inadequate intake, decreased absorption, and/or increased losses
Deficiency of certain micronutrients can depend on severity and location of disease
MVI with minerals recommended for all patients
Tietlebaum, J. Nutrient deficiencies in inflammatory bowel disease. 12 October 2011. Retrieved from: http://www.uptodate.com/contents/nutrient-deficiencies-in-inflammatory-bowel-disease?source=see_link
Poor Growth in Pediatric IBD
Is multifactorial: inadequate intake, inflammation, malabsorption, increased energy expenditure, use of glucocorticoids
Routine monitoring of growth parameters is key
Teitelnaum, J. Growth failure and poor weight gain in children with inflammatory bowel disease. 11 November 2012. Retrieved from: http://www.uptodate.com/contents/growth-failure-and-poor-weight-gain-in-children-with-inflammatory-bowel-disease?source=search_resultandsearch=growth+failure+and+poor+weight+gain+in+children+with+inflammatoryandselectedTitle=1%7E150
Nutrition Interventions for IBD
Counsel patient and family on well-balanced, calorically adequate diet to promote normal growth
Calorie requirements for catch-up growth range from 125-150% of the DRI for age/sex
No food restrictions unless specific intolerances are noted by the patient
Teitelnaum, J. Growth failure and poor weight gain in children with inflammatory bowel disease. 11 November 2012. Retrieved from: http://www.uptodate.com/contents/growth-failure-and-poor-weight-gain-in-children-with-inflammatory-bowel-disease?source=search_resultandsearch=growth+failure+and+poor+weight+gain+in+children+with+inflammatoryandselectedTitle=1%7E150
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Nutrition Interventions for IBD
Consider oral nutrition supplements such as Pediasure, Pediasure 1.5, or Boost Kid Essentials 1.5
Low cost alternative nutrition supplement for purchase such as Carnation Instant Breakfast
Scientific literature does not strongly support use of formula with intact proteins vs. semi-elemental or elemental
Semi-elemental formulas could be trialed if patient does not tolerate formula with intact proteins
Crtich, J. Day, A. Otley, A. King-Moore, C. Teitelbaum, J. Shashidhar, H. Use of Enteral Nutrition for Control of Intestinal Inflammation in Pediatric Crohn’s Disease. JPGN. 2012;54: 298-305.
Oral Nutrition Supplements
Intact protein oral supplements
Peptide based oral supplements
Enteral Nutrition for Crohn’s Disease
Enteral nutrition therapy Exclusive enteral feeds: sole dietary source utilized with
goal of inducing remission. All foods excluded
Partial enteral feeds: given overnight along with regular diet during the day to improve nutritional status
Not shown to be effective for ulcerative colitis
Parenteral nutrition therapy
Crtich, J. Day, A. Otley, A. King-Moore, C. Teitelbaum, J. Shashidhar, H. Use of Enteral Nutrition for Control of Intestinal Inflammation in Pediatric Crohn’s Disease. JPGN. 2012;54: 298-305.
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Celiac Disease
Chronic autoimmune intestinal disorder
Inflammation of the small intestine due to sensitivity to gluten
Villi in the intestine become inflamed and flattened resulting in malabsorption and GI symptoms
Golden diagnosis is endoscopy with intestinal biopsy
Must be exposed to gluten through diet for accurate diagnosis
Hill, I. Clinical Manifestations and diagnosis of celiac disease in children. 22 January 2013. Retrieved from: http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-celiac-disease-in-children?source=search_resultandsearch=celiac+diseaseandselectedTitle=3%7E150
Gluten Free Diet (GFD)
Only treatment option
Requires lifelong adherence
Complete dietary elimination of gluten (wheat, rye, barley)
Concern for cross-contamination
Possible lactose intolerance initially
Case, Shelley. Gluten Free Diet: A Comprehensive Resource Guide. Canada: Case Nutrition Counseling Inc., 2010. Print.
Oats and Gluten Free Diet
Commercial oat products likely to be contaminated with gluten
A small number of individuals may react to the protein in oats
Most experts agree that pure, uncontaminated gluten free oats can be safely consumed in limited amounts (1/4 cup of dry rolled oats for children)
Follow up with gastroenterologist and monitoring of antibody levels is important
Case, Shelley. Gluten Free Diet: A Comprehensive Resource Guide. Canada: Case Nutrition Counseling Inc., 2010. Print.
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Example
ExampleBEST INGREDIENTS: Gluten Free Toasted Oats (whole grain oats, organic cane sugar, canola oil, mixed tocopherols [contains soy]), Tapioca Syrup, Rice Crisp, Raisins, Palm Oil, Organic Tapioca Syrup Solids, Organic Cane Syrup, Rice Fiber, Organic Inulin, Natural Flavors, Organic Cinnamon, Organic Sunflower Lecithin, Sea Salt, Organic Annatto Extract (for color).CONTAINS SOY INGREDIENTS. Made on shared equipment that also processes tree nuts.
Gluten Free DietFoods to avoid:
Bread, cereal, pasta, baked goods, etc. containing wheat, rye, or barley as well as any cross-breeds or derivatives of these grains
Processed food products containing gluten
Foods allowed:
Fruits and vegetables
Most dairy products
Gluten free grains such as rice, corn, buckwheat, amaranth, quinoa, uncontaminated GF oats, etc.
Plain meat, fish, or poultry
Eggs
Beans, peas, lentils
Nuts and peanuts
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GF Options and WIC Package
Whole grains: rice, corn tortillas
Cereals: Rice and Corn Chex, Cream of Rice
Beans, lentils, and peas
Peanut butter
Milk, soy beverage, cheese, eggs
Juice
Gluten Free, Casein Free Diet for Autism
Involves dietary elimination of gluten and casein
Thought to help improve behavior, speech, and social skills of child with autism
Scientific evidence is lacking
If parent chooses to implement diet restrictions for their child, consultation with pediatric RD is strongly recommended
Mulloy, A. Lang, R., O’Reilly, M et al. Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders. 2010;4: 328-39.
Non-Celiac Gluten Sensitivity
Symptoms may include abdominal pain, bloating, diarrhea, constipation, headaches, fatigue, depression, etc.
Testing is negative for celiac disease and wheat allergy
Symptoms alleviated with elimination of gluten and return when gluten is reintroduced
Only treatment is gluten free diet
Quantity of gluten tolerated may vary from one individual to the next
Celiac Disease Foundation. Gluten Sensitivity. n.d. Web. 11 March 2014.