Sharlene Coombs, RD, CD, CSP, CNSD

Primary Children’s Medical Center

Sharlene.coombs@imail.org

6-25-2011

Foods, liquids, supplements and medications are taken by mouth

(or by tube).

Digestion and absorption occur in the

gastrointestinal tract.

Immune system responds as “foreign but safe”.

Food components are taken to body sites via blood for cell

renewal and energy.

Immune system responds as “foreign and a threat!”

Immune system defends the body. Inflammatory mediators are released into local tissues

and transported to distant sites in the body via blood.

OR

Inflammatory mediators are released and transported to distant sites

in the body via blood.

Allergy symptoms develop in body

Respiratory: congestion, runny nose, asthma Gastrointestinal: pain, upset stomach, diarrhea, nausea, vomiting Skin and mucous membranes: hives, itching, swelling, rashes Cardiovascular: low blood pressure, rapid and /or weak pulse Systemic: Anaphylaxis

� Restriction of offending food(s)

� Adequate calories and protein

� Adequate vitamins and minerals

� Establish and maintain good health

“Life with food allergies remain difficult, with the only reliable therapy being complete restriction or elimination of the responsible food(s) allergen and

emergency management of reactions when allergens are accidentally ingested…

…Ultimately, the balance must be found between

efforts to mitigate the disease and to sustain the overall quality of life.”

www.allergyadvisor.com

�  Seek appropriate medical help

�  Follow recommendations- get in writing

�  Follow thru on appts and/or call if problems continue

�  It does help to have food log or record of problems

�  Learn all you can about the foods to avoid

�  Learn to cook from “scratch”- back to basics though not easier than eating out or processed foods.

�  Caregivers need to support one another

�  Caregivers need to have eating plans �  All caregivers need to understand emergency plan

�  Infants and children with allergies may need more frequent weight and height evaluations

�  Provide the “best” nutrition you can- this may include high calorie foods- not just fruits and veg.

�  Buy & prepare appropriate/safe foods

�  Offer meals and snacks every 3-4 hours apart, for 5-6 opportunities to eat and drink each day

�  Do not allow sipping and grazing all day

�  At each meal and snack, offer protein, starch, fruit or vegetable and 4-6 oz milk or milk substitute �  1 Tbsp of each food group per year of age of the child

To eat or not to eat

It is ok for them to feel hunger-

a natural driving force to eat and drink

Do �  Offer reasonable

choices, ie white or chocolate milk, not water instead

�  It helps to be a good role model

�  Meal times should be pleasant, not centered on what the child is or is not eating

�  Force, punish or demand the child eat/drink

�  Give in to child’s demands- even if underweight

Don’t

Calories

Protein

Vitamins

Minerals

Fluids

�  Carbohydrates

�  Protein

�  Fat

�  Sugars, starches, fibers

�  Glucose is preferred source of energy

�  Many vitamins and minerals in CHO foods

�  Excess intake is stored in liver and converted to fat �  Foods: Sugars, starches, grains, fruits, vegs & dairy

�  Essential and non-essential amino acids

�  Amino acids build, repair and maintain body cells

�  Provide energy when CHO and fat are missing

�  Participate in chemical reactions in the body

�  Foods: Eggs, meats, fish, poultry, dairy, �  nuts, beans, grains

� Essential and non-essential fatty acids

�  Integral to the nervous system; insulation

� More calorie dense than CHO or protein

�  Foods: Dairy, butter, nuts, seeds, animal fat, coconut milk/oil, vegetable oils

�  Vitamins �  13 chemicals; various functions �  Fat and water soluble �  Essential for health

�  Minerals �  15 elements: various functions and structure �  Major and trace elements �  Essential for health

�  Water �  Provided from food and fluids �  Essential for health

�  Vitamin A �  Function: Vision, skin, membranes �  Food sources: liver, fish oil, dairy products

�  Vitamin E �  Function: Antioxidant, improves immune system �  Food Sources: nuts, seeds, oils, wheat germ

�  Vitamin K �  Function: blood clotting �  Food sources: Dark green veggies, liver, wheat bran

�  Vitamin D �  Function: Bone health, immunity, reproduction, insulin secretion. Maybe prevents certain cancers.

Children with low levels have higher incidence of food allergies.

�  Dietary Reference Intake: increased to 400-1300 IU �  Food sources: egg yolk, liver, fish oil, fortified milk

and milk substitutes. Also the “Sun”. �  Supplements: Liquid- “Wellesse” 2 tsps = 1000 IU.

Tablets: 500-50,000 IU.

�  Thiamin, B1 �  Riboflavin, B2 �  Niacin, B3 �  Pyridoxine, B6 �  Biotin (found in eggs, leafy greens) �  Pantothenic Acid

�  All function as coenzymes in metabolism �  Destroyed with overcooking, light and heat �  Foods: dairy, meats, legumes, whole grains, nuts

�  Vitamin C �  Function: Antioxidant, healthy bones, gums, teeth,

blood vessels, brain function, iron absorption �  Foods: Citrus fruits, bell peppers, tomato, kiwi, red berries

�  Folate, folic acid, B9 �  Function: Synthesis for DNA, gene expression &

regulation. Critical 21-27 days after conception. �  Foods: Orange juice, leafy greens, yeast, liver, soy,

fortified grains, broccoli, eggs

�  Calcium �  Function: Bones, muscle contraction, blood clotting �  Vitamin D helps absorption. Excess protein, salt,

caffeine and alcohol decrease absorption. �  Foods: Dairy, fortified foods and drinks, nuts,

legumes, dark greens ( limited absorption) �  Dietary Reference Intake: (recommended intake)

Age Calcium, mg/day 1-3 years 700 4-8 years 1000 9-18 years 1300 19-50 years 1000 51 + years 1200

�  Phosphorous

�  Function: Bones, teeth, cell membranes, enzymes �  Balance of calcium and Vitamin D needed �  Diet often restricted in kidney failure �  Foods: Dairy, meats, poultry, fish, eggs, soda pop �  Not usually supplemented

�  Iron �  Function: transports oxygen, picks up CO2, healthy

immune system, growth, cognition, DNA synthesis �  Foods: meat, fish, poultry, dark green leafy veg. �  Vit. C increases absorption. Calcium prevents.

�  Zinc �  Function: DNA/RNA, cell division, wound healing,

part of enzymes, needed for bone growth. �  Foods: meats, wheat germ, shellfish, liver, cheese,

eggs, whole grains, nuts/seeds, legumes

�  Magnesium �  Function: enzyme systems, glucose metabolism,

bone health, prevent dental caries, muscle function �  Foods: Beans, whole grains, seafood, leafy greens

�  Iodine �  Function: Essential for thyroid hormones, regulate

body temp., metabolic rate, growth, reproduction �  Foods: iodized salt, saltwater fish/seafood

�  Iodized salt is not used in processed foods.

�  Fluoride �  Function: Interferes with plaque formation �  Foods: Fortified drinking water, small amounts in

fruits & veg. �  Sodium

�  Function: acid-base balance, fluid balance, muscle/nerve activation- small amount, but essential.

�  Foods: table salt, cheese, dairy, processed foods �  Potassium

�  Function: similar to sodium �  Foods: vegetables, fruits, dairy, meats, grains

�  Chromium �  Whole grains, wheat germ ,liver, meat

�  Copper �  Bread, potatoes, grains, dried beans, nuts, seeds

�  Chloride �  Table salt

�  Manganese �  Whole grains, coffee, tea, dried beans, nuts

�  Molybdenum �  Whole grains, wheat germ, liver, meat

Milk + + + + + + Soy + + + + + + Egg + + + + + + + + Wheat + + + + Peanut + + + + Tree nut + + + Fish/shellfish + + + + + +

A D E C B1 B2 B3 B6 B12 B9 Vitamin

Food

Includes fortified/enriched cereals and flours. Fortified/enriched soy milks. Cheeses, yogurt, ice cream not usually fortified with Vit D

Milk + + + + + Soy + + + + Egg + + Wheat + + + + + Peanut + + + + Tree nut + + + + Fish/shellfish + + + + + +

Calcium Iron Zinc Mag. Sodium Potassium Mineral

Food

Includes fortified wheat cereals and flours. Fortified soy milks. Salted nuts and saltwater seafood

�  Optimal amount based on weight (textbook)

�  0-10 kg= 100 ml/kg �  10-20 kg= 1000 ml + 50 ml for every kg >10 kg �  20+ kg= 1000 ml + 20 ml for every kg >20 kg

�  Weight in lbs divided by 2.2 = kg �  Divide total ml’s by 30 ml/oz = ounces

�  Fiber

�  Prebiotics and Probiotics

� Omega 3 fatty acids

�  Replace with comparable foods or drinks �  Look for fortified products

�  Take vitamin/mineral supplements

�  Monitor weight/growth

�  Consider monitoring blood work for key nutrients �  Vit D, iron, zinc

Drink Calories Protein, grams Calcium, mg Cow’s milk, whole 150 8 276 Soy milk* 100-130 6 300-350 Rice milk* 120-130 1 300 Coconut milk* 80-550 1-5 100-450 Hemp milk* 100 4 300 Oat milk* 130 4 100 Potato milk* 70-110 0 300 Almond milk 40-90 1 200-450 Orange juice* (some) 110 2 350 Elecare, 30 kcal/oz 240 7.4 278 Neocate Jr 240 7.9 271 Splash 237 5.9 147

Comparison of Cow Milk Alternatives (8 oz)

*Calcium is not naturally occurring- fortified

�  http://www.nal.usda.gov/fnic/foodcomp/search/

Non-Wheat Grains �  Amaranth �  Arrowroot �  Barley �  Buckwheat/Kasha �  Corn �  Lentil or pea flour �  Millet �  Nuts/seed meal or flours �  Oat �  Potato �  Quinoa �  Rice �  Rye �  Soy flour �  Tapioca �  Pre-made wheat/gluten free

flour mixes

�  Amaranth �  Arrowroot �  Buckwheat/Kasha �  Corn �  Lentil or pea flours �  Millet �  Nuts/seed flours �  Potato �  Quinoa �  Rice �  Soy flour �  Tapioca �  Pre-made wheat/gluten free

flour mixes

Gluten Free Grains

�  40-50% of infants with cow milk allergy, will also have soy allergy. This is why soy formulas are not recommended for infants with CMA

�  Soy can be found in most shortenings, margarines,

vegetable sprays, Asian/oriental foods

�  Soy protein is added to processed and commercial foods to improve nutritional quality.

�  Soy oils and soy lecithin usually safe- if very sensitive, then avoid.

�  Soy restricted diet alone should not compromise nutrition intake

�  Avoid eggs from all bird species

�  Look for “egg” in baked goods, sauces, salad dressings, breaded foods, pastas, candies, desserts, used as binders as in meatloaf, used as garnish, washed on bread, rolls, pies.

�  Learn to cook with substitutes for egg as leavening agent or as binders.

�  Egg restricted diet alone should not compromise nutritional intake.

�  Peanuts are not related to Tree nuts. However, there is high chance of cross-contamination.

�  Refined peanut oil should be safe, but no guarantee, so avoid it if high risk of anaphylaxis.

�  Peanut or other nuts can be found in or cross contaminated in candies, ice creams, some cheese spreads.

�  Seeds or seed butters may be alternatives.

�  Peanut or tree nut restricted diets alone should not compromise nutritional intake.

�  Know the species you are allergic to. If allergic to one type of shellfish, avoid all. Do not always need to restrict other fish if allergic to one species.

�  Fish oil likely to be contaminated with fish protein,

including Omega 3 fish oils, so avoid if allergic.

�  Fish or shellfish may be in Asian, Thai, Chinese foods, baked goods, cookies, candies, any food containing gelatin. Be aware of Omega 3 fish oil added to many foods for health benefits.

�  Fish and Shellfish restricted diets alone should not compromise nutritional intake.

�  Do we need them? �  No-

�  If taking 32 oz/day of “complete” formula or �  If eating wide variety of foods, from all food groups

�  Maybe- if avoiding one major food group

�  Probably- if avoiding two major food groups

�  Definitely- if avoiding 3 or more food groups �  Everyone needs calcium/Vit D supplement- if avoiding milk and not taking 32 oz/day fortified

milk substitute or ”complete” formula

�  What kind? �  Generic might be ok if hypoallergenic �  Hypoallergenic are available-

�  Costly �  Online: www.solacenutrition.com �  read labels carefully or ask pharmacist

�  “Complete”- should have 100% of RDA, including iron and

zinc. Most won’t have much calcium. �  ½ to 1 tablet/day of Children’s chewable “complete” �  Gummies type are not “complete”

�  May need additional nutrients, (Vit D, iron) if lab data indicate deficiencies.

�  Take in divided doses, no more than 500 mg at a time, preferably with food.

�  Vit D and Vit C improve absorption.

�  High fiber diet decreases absorption

�  Iron competes for absorption. �  Pills, chewable candies or liquid forms available.

�  Calcium carbonate, calcium citrate �  Read labels carefully for allergen ingredients �  Usually <100 mg in children’s chewable vitamins. �  Calcium is not in infant/children’s liquid vitamins.

�  FDA regulated

�  Infant (0-12 months), Pediatric (1-10 year), Adult �  meets RDA for nutrients in ~1000 ml’s (33.3 oz) for ages

one year and older.

�  Standard and special needs: For drinking or tube fed

�  Care for just like food- re: handling, mixing, storing

�  Powder, liquid concentrate, ready to feed

�  Can Sustain life- provide “Total” nutrition

�  Milk based: �  Infant: Enfamil, Similac, Good Start, generic �  Pediatric: Pediasure, Boost Kids Essential, Nutren Jr �  Adult: Ensure, Nutren, others

�  Soy based: �  Infant: Prosobee, Isomil, generic �  Pediatric: Pediatric Soy Bright Beginnings �  Adult: Fibersource

�  Partially hydrolyzed Milk: �  Infant: Nutramigen, Alimentum, Pregestimil �  Pediatric: Peptamen Jr, Vital Jr (new name: Pediasure Peptide)

�  Adult: Peptamen

�  Elemental formulas �  100% amino acid, most simple form of protein �  Useful in milk, soy, or hydrolysate formula allergy

and intolerances, GERD, poor growth, EOE �  Total nutrition in ~33 oz/day �  Taste

�  Varied flavors or unflavored for tube feeds �  Cost

�  Very expensive. Medicaid and some insurance will cover, (depending on diagnosis)

�  Availability �  Not available in grocery stores �  Is available from WIC (1-5 years old), Homecare

pharmacies, mail order pharmacies, web based companies, and thru manufacturers

�  Abbott Nutrition: www.abbottnutrition.com �  Infant

�  Infant Elecare: unflavored, powder, 20 kcal/oz �  Pediatric – 1-10 years

�  Elecare Jr(new name): vanilla and unflavored, powder, 30 kcal/oz

�  Nestle: www.nestlenutritionstore.com �  Pediatric – 1 year or older

�  Pediatric Vivonex: unflavored, powder, 24 kcal/oz, �  Adult

�  Vivonex plus: 30 kcal/oz, adult �  Tolerex: 30 kcal/oz, adult

�  All unflavored, powder, used for tube feeds

�  Mead Johnson: www.enfamil.com �  Infant

�  Nutramigen AA: 20 kcal/oz, powder, unflavored,

�  Nutricia North America: www.nutricia-na.com �  Infant

�  Neocate with DHA and ARA: 20 kcal/oz, powder, unflav. �  Neocate nutra: corn based semi-solid food for >6 month

�  Pediatric �  Neocate Jr: 30 kcal/oz, 3 flavors, powder �  EO28 Splash: 30 kcal/oz, 3 flavors, juice box

Sharlene Coombs, RD, CD, CSP, CNSD