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Diet and nutritional status of children with food allergies

F O O D A L L E R G Y A N D A N A P H Y L A X I S Diet and nutritional status of children with food allergies Sophie Flammarion1, Clarisse Santos1, Dominique Guimber2, Lyne Jouannic3,Caroline Thumerelle1, Fre´de´ric Gottrand2 & Antoine Deschildre1 1Unite´ de pneumologie et allergologie pe´diatriques, de´partement de pe´diatrie, ho´pital Jeanne de Flandre, CHRU de Lille, France, 2Unite´ degastroente´rologie et nutrition pe´diatriques, de´partement de pe´diatrie, ho´pital Jeanne de Flandre, CHRU de Lille, France, 3Service de die´te´- tique, de´partement de pe´diatrie, ho´pital Jeanne de Flandre, CHRU de Lille, France To cite this article: Flammarion S, Santos C, Guimber D, Jouannic L, Thumerelle C, Gottrand F, Deschildre A. Diet and nutritional status of children with food allergies. Pediatr Allergy Immunol 2011; 22: 161–165.
The aim of the present study was to assess the food intakes and nutritional status nutritional status; nutrient intakes; child of children with food allergies following an elimination diet. We conducted a cross sectional study including 96 children (mean age 4.7 ± 2.5 years) with food allergies and 95 paired controls (mean age 4.7 ± 2.7 years) without food allergies. Nutri- tional status was assessed using measurements of weight and height and Z scores pe´diatrique, Ho´pital Jeanne de Flandre, for weight-for-age, height-for-age and weight-for-height. Nutrient intakes assessment Avenue Euge`ne Avine´e, CHRU de Lille, 59 was based on a 3-day diet record. Children with food allergies had weight-for-age and height-for-age Z scores lower than controls (0.1 versus 0.6 and 0.2 versus 0.8 respectively). Children with 3 or more food allergies were smaller than those with 2 or less food allergies (p = 0.04). A total of 62 children with food allergies and 52 controls completed usable diet records. Energy, protein and calcium intakes weresimilar in the two groups. Children with food allergies were smaller for their age Accepted for publication 21 February 2010 than controls even when they received similar nutrient intakes. Nutritional evalua-tion is essential for the follow up of children with food allergies.
The prevalence of food allergies is increasing worldwide and is currently estimated at 4.7% in the French school-aged population (1). Food-induced allergic reactions are responsi-ble for a variety of symptoms involving the skin, gastrointes- This research was a cross-sectional study of children with at tinal tract and respiratory tract (2). The main foods least one food allergy referred to the Pediatric Pulmonology and responsible for food allergies are cow’s milk, eggs and pea- Allergology Unit of Jeanne de Flandre University Hospital in nuts. Kiwi fruits and tree nuts are also increasingly common Lille between March and June 2005. Children were included if allergies in the French paediatric population (1). The only they had a proven food allergy treated by an elimination diet for proven therapy for food allergies is the strict removal of the at least 4 months, were more than 6 months and <15 yr old, identified food allergens from the diet. This requires careful and were following a diversified diet at the time of the study.
dietary evaluation and education (3). Therapeutic elimination Exclusion criteria were any other associated chronic diseases, diets have been shown to reduce the symptoms of food aller- nutritional support (enteral or parenteral) or a history of diges- gies but could be responsible for nutrient deficiencies and tive surgery. Diagnoses of food allergies were based on clinical failure to thrive, especially if a significant number of foods symptoms of allergies, associated with either positive skin prick are avoided (4–6). A few previous studies have reported tests or food-specific immunoglobulin E (IgE), or on a positive reduced growth despite normal energy intakes in children oral food challenge. Skin prick tests used commercially pre- with food allergies (7–10). The aim of our study was to assess pared extracts (Stallerge`nesÒ, Anthony, France) or native nutrient intakes and nutritional status in a group of children foods. They were positive for a wheal of at least 3 mm. Specific with food allergies following an elimination diet.
IgE were dosed with Cap system (PhadiaÒ, Uppsala, Sweden).
Pediatric Allergy and Immunology 22 (2011) 161–165 ª 2010 John Wiley & Sons A/S Nutritional status of food allergic children Records were taken of the number and type of foods mean difference and 95% confidence interval (95% CI) were involved. Clinical signs of allergy (asthma, eczema and diges- indicated. Fisher tests were used to make proportional com- tive symptoms) at diagnosis and at the time of study were parisons of the children. Results were reported for a signifi- recorded. Asthma control was assessed at the time of study cance level of p < 0.05. Statistical analyses were performed according to GINA guidelines and classified as controlled or using the SPSS. 13 (Chicago, Illinois, USA) program for not controlled (partly and uncontrolled levels). Eczema sever- ity at the time of study was classified as controlled, localizedskin involvement or severe skin involvement. Inhaled cortico- steroid (ICS) and topical steroid treatments received at thetime of study were also recorded. ICS doses higher than We studied 96 children (60 boys and 36 girls) with food aller- 400 lg/day of fluticasone were considered as high doses.
gies whose mean age was 4.7 (SD 2.58). Their mean weight The children with food allergies were paired for age and was 17.8 kg (SD 8.3 kg) and their mean height was 103.9 cm sex with control children with no food allergy. Identical (SD 19.5 cm). Among the 96 children with food allergies, 61 inclusion and exclusion criteria were applied to the controls, (63%) had a history of atopic dermatitis, 38 (40%) had acute except that they had no food allergies and followed no elimi- urticaria, 66 (69%) had asthma, 32 (33%) had gastrointesti- nal symptoms (diarrhoea, vomiting, or constipation), 6 (6%)had oral allergic syndrome, and 4 (4%) had rhino conjuncti-vitis. None had a history of anaphylactic shock. Sixty-three (65%) children had more than one symptom. At the time of Children were weighed wearing light clothes using electronic study, asthma was controlled for 32 children. Fifty-one chil- scales, and their heights were measured. All weights and dren received ICS, with 28 receiving high doses of ICS and heights were compared to Sempe´ reference values for French 24 receiving combined ICS and long-acting beta2-adrenergics.
children (11). Weight-for-age (W/A), height-for-age (H/A) Thirty-three children had persistent atopic dermatitis, among and weight-for-height (W/H) were converted into Z scores.
those seven had severe skin involvement. Thirty children weretreated with topical steroids and four with topical tacrolimus.
No children had persistent gastrointestinal symptoms at the The daily nutrient intakes were assessed using a 3-day diet The main foods involved were peanuts for 59 children record (12). The parents of all the children taking part in the (61%), eggs for 50 children (52%), cow’s milk for 28 children study were contacted by telephone 3 wk prior to consulta- (29%), soybeans for 15 children (15%) and fish for 10 chil- tion. They were asked to fill in a 3-day diet record report in dren (10%). Thirty-three children (34%) were allergic to one the form of a printed chart sent to them through the mail.
food only, 22 (23%) to two foods and 41 (43%) children to The charts included explanations about how to record the three foods or more. Among the 96 children with food aller- food consumed and how to make measurements using com- gies, 85 (88%) had received nutrition counselling by a trained mon instruments such as graduated bowls, cups, dishes and dietician at the time of the study, the other 11 children had spoons. Oral instructions were also given to each parent on been counselled by their paediatrician.
how to keep accurate records. Each page of the report corre- The control group included 95 children (59 boys and 36 sponded to 1 day and was separated in five parts: breakfast, girls) with a mean age of 4.7 (SD 2.7). Their mean weight lunch, tea and dinner and snacks. The same dietician was 17.9 kg (SD 6.2 kg) and their mean height was 104.9 cm reviewed each individual report and checked the quantity of all meals and drinks. The dietician was experienced in identi-fying reporting errors and the plausibility of food recording.
The portion sizes were estimated using a three-dimensionalportion chart instrument including photographs of common W/A and H/A Z scores of the children with food allergies foods corresponding to exact quantities. Calculations of were lower than those of the children in the control group energy, proteins, carbohydrates, fat, calcium, phosphorus, (mean difference )0.5, 95% CI [)0.95; )0.05], p = 0.01 and iron, magnesium, and vitamins A, D, C and E were all made mean difference )0.56, 95% CI [)1.02; )0.09], p = 0.03) using Winrest 32Ò (Paris, France) programme using French (Table 1). The mean W/H Z score representing global nutri- foods composition tables and manufacturers’ data (13). The tional status was similar in the two groups. However, nutrient intakes were compared to the recommended dietary although the global nutritional status in both groups was intakes for healthy children in France (14). There were no normal, the children with food allergies were smaller than available reference values for carbohydrate and fat intakes.
those in the control group. Nine children with food allergieshad W/A Z scores <)2 and seven had H/A Z scores <)2,no control children had W/A Z scores <)2 and two controls only had H/A Z scores <)2 (p = 0.01 and p = 0.03, Means and standard deviation (SD) were used to describe the quantitative data. The two groups were compared using Children allergic to three foods or more were smaller than Mann–Whitney tests. When the difference was significant, the children allergic to one or two foods (p = 0.03) (Table 2).
Pediatric Allergy and Immunology 22 (2011) 161–165 ª 2010 John Wiley & Sons A/S Nutritional status of food allergic children Table 1 Nutritional status of children with food allergies compared to those in the control population (Table 3). Daily calcium intakes were similar in the two groups, whether or not thecalcium supplement was included in the assessment, and both groups met the recommended levels. Vitamin A and E intakes were higher in children with food allergies than in controls. Vitamin D intake from food was similar in both groups but both were below the recommended Of the 28 children allergic to cow’s milk, 14 received cal- cium supplement and 27 received cow’s milk substitutes: three received soy-based formula, 16 received extensively hydrolysed formulas and eight received amino acid-basedformula. Energy intakes among those children were equiva- There was no difference in the W/A and H/A Z scores of lent to controls. Their protein intakes met with recommended children with food allergies depending on the existence of levels but were lower than controls (mean difference )19.8 g, eczema or asthma or gastrointestinal symptoms. Nor was 95% CI [)27.6; )12.1], p = 0.03). Their food calcium intakes there any difference in these scores depending on treatment were also lower than controls (mean difference )287.7 mg, 95% CI [)433.9; )141.5], p = 0.007), but their total calciumintake including supplements met with the recommended lev-els and was equivalent to controls.
Energy intakes of children with food allergies who had A total of 62 (65%) out of the 96 children with food aller- had a dietician consultation were not different from those gies and 52 (55%) of the children in the control group who did not have professional counselling. Equally, energy completed usable diet records. There was no difference in intakes of children allergic to one or two foods were not dif- the growth of children who had filled their records and ferent from those of the children allergic to three foods or those who had not. The mean energy intakes of both pop- ulations met with recommended levels but 24% of childrenwith food allergies and 23% of controls received energy intakes of both populations were superior to recommended We described nutrient intakes and growth parameters in food levels. Children with food allergies had equivalent energy, allergic children who had received nutrition counselling by a proteins, fat, carbohydrates, phosphorus and iron intakes dietician. A small number of studies about this subject existin the literature. They mostly concern children allergic tocow’s milk (7–9). We found that children with various aller- Table 2 Nutritional status of children according to the number of gies had weight and height within the range of normality but were smaller and lighter for their age than the controls. Chil-dren allergic to three or more foods were smaller than chil- dren allergic to one or two foods. Growth was not influenced by the existence of asthma, nor by treatment with ICS or topical steroids. The nutrient intakes of children with food allergies met with the nutritional recommendations and were similar to the intakes of the control children. No difference in energy and nutrient intakes was observed between the two populations or according to the number of foods the children We studied children with allergies to various foods, but our population might not represent the global population of children with food allergies. The children came from a ter- tiary hospital to which they were referred because of the severity of their allergies. They had a high prevalence of mul- tiple food allergies, and most of them had received special- ized dietetic advice. The diagnosis of food allergy in our population fulfilled the criteria described earlier but was not always ascertained by a positive oral food challenge (2, 15).
This could lead to an overestimation of the number of multi- ple food allergic children. The dietary record method we used *p < 0.05 compared to allergies to 1 or 2 foods.
to evaluate nutrient intake can provide quantitatively accu- rate information on food consumed during the recording Pediatric Allergy and Immunology 22 (2011) 161–165 ª 2010 John Wiley & Sons A/S Nutritional status of food allergic children Table 3 Daily nutrient intakes of children with food allergies com- tent intestinal inflammation could be caused by continuous antigen challenge from non-compliance with the diet, undi-agnosed allergy or antigen remnants in the substitute for- mula. Amino acid-based formulas have been reported to effectively alleviate residual symptoms that do not respond to hydrolysates in cow’s milk allergy (18, 19). Another pos- sible explanation could be the higher caloric and proteinneeds of children with moderate to severe atopic dermatitis based on the degree of skin involvement. Isolauri et al.
found that the albumin of children with cow’s milk allergy and atopic dermatitis was lower than healthy controls hav- ing the same protein intakes (16). In our study, 63% of the children with food allergies had atopic dermatitis, 38% had persistent symptoms. However, we did not find any differ- ence in the growth of children with and without atopic der- matitis in our population. We also evaluated the growth of food allergic children depending on asthmatic symptoms.
ICS could affect the growth pattern of asthmatic children although the growth deceleration may be compensated after the first year of treatment (20, 21). We did not find any dif-ference between the growth of the 69% of children with asthma in our study (whether or not they received inhaled SD, standard deviation; RDA, recommended daily allowance.
steroids) and those without asthma. We did not evaluatethe duration of steroid treatment.
period but may alter dietary behaviour during the recording In our study, we evaluated calcium and other nutrient period (12). Finally, our aim was a focus on the nutritional intakes. Children allergic to cow’s milk had food calcium status at the time of the study. We assessed the severity of intakes lower than controls. Their total calcium intakes the symptoms during but not prior to the elimination diet.
including calcium supplements were normal and similar to We did not follow-up the growth of the children during elim- controls. This confirms the result of Tianen study, where chil- ination diet, and therefore, we could not evaluate their dren allergic to cow’s milk also received milk substitutes and calcium supplement (7). Children allergic to cow’s milk We found a relationship between the number of foods the receiving no or little calcium supplement have calcium children were allergic to and their height. This confirms the intakes lower than controls (22, 23). This result enhances the results found in a similar study comparing 98 children with importance of milk substitution by extensively hydrolysed various food allergies to control children with no food formulas or amino acid-based formula and appropriate cal- allergy. Children allergic to two or more foods were smaller cium supplement in cow milk-allergic children. The increased than those allergic to only one food (10).
vitamin E and A intakes in children with food allergies can We confirmed previous studies assessing the growth of be explained by the addition of vegetable oils as recom- children allergic to cow’s milk showing that they were smaller than controls despite similar energy intakes (6–8). Isaulori etal. studied the growth of 100 children (median age 7 months) allergic to cow’s milk following an elimination diet includingmilk substitute and calcium supplement. Their W/A and H/A Our study confirms the importance of a global approach for Z scores were lower than controls with energy and protein children with food allergies to ensure diagnosis, treatment, intakes following recommendations. There was no catch-up adequate diet and growth survey. Concerning the diet strat- growth at the age of 24 months (16).
egy, this should include the following: (1) a careful initial In our study, inadequate nutrient intake cannot explain education about label reading, hidden allergens and advice the difference in the growth pattern of children with food on food substitutes; (2) regular assessment of the degree of allergies. With appropriate nutrition counselling, children compliance with the eviction diet; (3) initial and regular with food allergies managed to have nutrient intakes match- assessment of nutrient intakes to detect nutritional deficien- ing the recommended levels and similar to non-allergic chil- cies and give adequate substitutes and supplements; and (4) dren having normal growth. One possible explanation could be the loss of nutrients caused by continuous allergicinflammation and abnormal intestinal permeability despite the eviction diet (17). We did not find any difference in thegrowth of children with and without a history of gastro- We express our profound thanks to all the families who par- intestinal symptoms in our population but no children had ticipated in the study and to the department of dietetics for persistent digestive symptoms under elimination diet. Persis- Pediatric Allergy and Immunology 22 (2011) 161–165 ª 2010 John Wiley & Sons A/S Nutritional status of food allergic children 1. Rance F, Grandmottet X, Grandjean H.
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A. Intestinal barrier: an interface between schoolchildren diagnosed with food allergies 10. Christie L, Hine RJ, Parker JG, Burks W.
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11. Sempe´ M, Pe´dron G, Roy-Pernot MP. Aux- cacy and safety of hydrolyzed cow milk and 3. Modifi S. Nutritional management of pediat- ologie me´thode et se´quence. Paris: The´rap- amino acid-derived formulas in infants with ric food hypersensitivity. Pediatrics 2003: cow milk allergy. J Pediatr 1995: 127: 550–7.
12. Thompson FE, Byers T. Dietary assessment 19. Hill DJ, Murch SH, Rafferty K, Wallis P, 4. Noimark L, Cox HE. Nutritional problems resource manual. J Nutr 1994: 124: 2245S– Green CJ. The efficacy of amino acid-based related to food allergy in childhood. Pediatr formulas in relieving the symptoms of cow’s 13. Favier JC, Ireland-Ripert J, Toque C, Fein- milk allergy: a systematic review. Clin Exp 5. Fox AT, Du Toit G, Lang A, Lack G. Food berg M. Re´pertoire ge´ne´ral des aliments – allergy as a risk factor for nutritional rick- 20. Agertoft L, Pedersen S. Effect of long-term ets. Pediatr Allergy Immunol 2004: 15: 566– treatment with inhaled budesonide on adult 14. Martin A. Besoins nutritionnels et apports 6. Laitinen K, Isolauri E. Allergic infants: nutritionnels conseille´s. In: Martin A, ed.
growth and implications while on exclusion Apports nutritionnels conseille´s pour la pop- diets. Nestle Nutr Workshop Ser Pediatr Pro- Panagiotakos DB, et al. Growth deceleration of children on inhaled corticosteroids is 7. Tiainen JM, Nuutinen OM, Kalavainen MP.
15. Sicherer SH, Teuber S, Adverse Reactions compensated for after the first 12 months of Diet and nutritional status in children with treatment. Pediatr Pulmonol 2007: 42: 465– cow’s milk allergy. Eur J Clin Nutr 1995: 49: reactions to foods. J Allergy Clin Immunol 22. Henri Henriksen C, Eggesbo M, Halvorsen 8. Jensen VB, Jorgensen IM, Rasmussen KB, Molgaard C, Prahl P. Bone mineral status in 16. Isolauri E, Sutas Y, Salo MK, Isosomppi R, year-old children on cows’ milk-restricted Kaila M. Elimination diet in cow’s milk diets. Acta Paediatr 2000: 89: 272–8.
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intake and cows’ milk-free diets. Arch Dis E. Follow-up of nutritional status and die- Pediatric Allergy and Immunology 22 (2011) 161–165 ª 2010 John Wiley & Sons A/S

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