The practical dietary management of food protein-induced enterocolitis syndrome.

OBJECTIVE: Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E-mediated food allergy with potential risk of malnutrition related to the early onset of disease, frequent avoidance of cow's milk, and the possibility of multiple food triggers. This publication is aimed at providing an evidence-based, practical approach to the dietary management of FPIES. DATA SOURCES: This is a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to evaluate for nutritional risk and develop guidance for risk reduction in children with FPIES. STUDY SELECTIONS: We have included retrospective clinical cohort studies, population-based studies, case reports, and case studies. We did not exclude any studies identified owing to the small number of studies addressing the nutritional management of individuals with FPIES. RESULTS: Children with FPIES are at risk of malnutrition owing to suboptimal oral intake, limited food choices, and knowledge deficits related to feeding. In particular, children with 3 or more FPIES triggers seem to be at increased risk for poor weight gain and developing food aversion. Caregivers of children with FPIES also report a high degree of psychosocial burden. CONCLUSION: Appropriate dietary management entails the following 3 essential components: supporting normal growth and development, avoidance of allergens, and advancement of complementary foods. Education to avoid the trigger food and assisting caregivers in creating an individualized, well-designed complementary feeding plan to meet the infant's nutritional needs for optimal growth and development are essential management strategies.

Retinoic Acid Ameliorates the Severity of Food Allergy under Allergen Exposure in a Mouse Model with Food Allergy.

Effectiveness of retinoic acid (RA) in treating food allergy is not yet clear. Using an allergic mouse model, we examined the amelioration of the severity of food allergy by daily RA intake with allergen or without. Female Balb/c mice were systemically sensitized to egg white (EW) and alum by intraperitoneal injection. Sensitized mice were provided diets supplemented with 0% (non-treated group), 0.1% EW (allergen group), 0.0017% RA (RA group), or 0.1% EW plus 0.0017% RA (RA+allergen group) with 20% casein for 4 wk. Oral food challenge (OFC) and allergic biomarkers were quantified. The decrease in rectal temperature post-OFC was significantly suppressed in the RA and RA+allergen groups compared to those in the non-treated and allergen groups, respectivety. The plasma levels of ovalbumin-specific IgE, IgA and IgG1 at the study endpoint were higher in the allergen and RA+allergen groups than those in the non-treated and RA+allergen groups, respectivety. Plasma ovalbumin-specific IgG2a levels at the study endpoint were significantly higher in the RA+allergen group than those in the RA groups. The supernatant concentrations of interleukin-10 and interferon-γ in the cultured spleen lymphocytes were highest in the RA+allergen group compared to those in the other groups. Thus, continuous intake of RA under allergen exposure ameliorated the severity of food allergy in a mouse model with food allergy.

LTP allergy/sensitization in a pediatric population.

Plant lipid transfer proteins (LTPs) are widespread plant food allergens, highly resistant to food processing and to the gastrointestinal environment, which have been described as the most common food allergens in the Mediterranean area. LTP allergy is widely described in adults, but it represents an emerging allergen also in the pediatric population. Little is known about the real prevalence and the clinical features of this allergy in children and it still often remains underdiagnosed in these patients. An early identification and a deeper knowledge of this allergy in childhood can avoid severe systemic reactions and improve the child's quality of life. Pediatricians should always consider the possibility of LTP involvement in cases of plant-derived food allergy.

Personalized Nutrition Approach in Food Allergy: Is It Prime Time Yet?

The prevalence of food allergy appears to be steadily increasing in infants and young children. One of the major challenges of modern clinical nutrition is the implementation of individualized nutritional recommendations. The management of food allergy (FA) has seen major changes in recent years. While strict allergen avoidance is still the key treatment principle, it is increasingly clear that the avoidance diet should be tailored according to the patient FA phenotype. Furthermore, new insights into the gut microbiome and immune system explain the rising interest in tolerance induction and immunomodulation by microbiota-targeted dietary intervention. This review article focuses on the nutritional management of IgE mediated food allergy, mainly focusing on different aspects of the avoidance diet. A personalized approach to managing the food allergic individual is becoming more feasible as we are learning more about diagnostic modalities and allergic phenotypes. However, some unmet needs should be addressed to fully attain this goal.

Nutritional Issues in Food Allergy.

Diet and nutrition play an important role in the development and management of food allergy. The diet of expectant mothers can have an effect on their offspring in terms of allergic outcomes. A host of confounding factors may influence this, with a maternal diet rich in fruits and vegetables, fish, vitamin D-rich foods associated with a lower risk of allergic disease in their children. More surprisingly, the consumption of milk and butter has also been shown to have a protective effect, especially in a farm environment. Similarly, the diet of the infant can also be important, not only in terms of breast feeding, but also the timing of the introduction of complementary foods, the diversity of the diet and the effect of individual foods on the development of allergy. One factor which has clearly been shown not to influence the development of food allergy is allergen avoidance by expectant mothers. In the infant diet, the manipulation of the gut microbiome to prevent the development of atopic disease is clearly an area which promises much, although studies have yet to provide a breakthrough in the prevention of atopic dermatitis. More concrete evidence of the value of diet in prevention has come from studies evaluating infant eating patterns which may protect gut health, through the consumption of large amounts of home-processed fruits and vegetables. The consumption of fish during the first year of life has also been shown to be protective. The importance of nutritional issues in children and adults who have a food allergy has become much more accepted in recent years. The primary allergenic foods in infancy and childhood, milk, egg, wheat and soy are also ones which are present in many foods and thus their avoidance can be problematic from a nutritional perspective. Thus, children with a food allergy can have their growth compromised through avoidance, especially pre-diagnosis, when foods may be excluded without any expert nutritional input. The management of a food allergy largely remains the exclusion of the offending food(s), but it is now clear that in doing so, children in particular can be at nutritional risk if insufficient attention is paid to the rest of the diet. Adults with food allergy are often thought not to need nutritional counselling; however, many will exclude a wide range of foods due to anxiety about trace exposure, or similar foods causing reactions. The avoidance of staple foods such as milk and wheat are common, but substitute foods very often do not have comparable nutritional profiles. Adults may also be more susceptible to on-line promotion of extreme nutritional regimes which can be extremely harmful. All food allergic individuals, whatever their age, should have a nutrition review to ensure they are consuming a healthy, balanced diet, and are not avoiding food groups unnecessarily.

Impact of Food Immunoglobulin G-Based Elimination Diet on Subsequent Food Immunoglobulin G and Quality of Life in Overweight/Obese Adults.

OBJECTIVES: The goal of this study was to assess changes in serum immunoglobulin G (IgG) food antibody titers and quality-of-life measurements following a targeted elimination diet in overweight/obese adults. METHODS: We performed a randomized control trial. Participants were randomized in a 2:1 ratio to either an intervention group or waitlist group for 3 months. Food IgG testing was performed on all participants. The intervention group was instructed to eliminate up to 10 foods, for which they had high titers of IgG and communicated with health coaches for nutritional counseling for meal planning and adherence. The waitlist group did not receive their IgG testing results or health coaching. Primary outcome was serum IgG titers for foods eliminated during the trial, compared with baseline concentrations. Secondary outcomes were health-related quality of life measured by Patient-Reported Outcomes Measurement Information System (PROMIS-29) and change in participant-identified symptom severity measured by Measure Yourself Medical Outcome Profile. Exploratory outcomes were changes in body weight and waist circumference. RESULTS: IgG antibody concentrations decreased in 83% of the targeted foods in the treatment group and in 60% of the foods in the waitlist group, but this was not found to be a statistically significant difference. The intervention group reported improvement in sleep during the trial compared with waitlist, which was the only statistically significant finding in the study. CONCLUSIONS: The findings are consistent with changes in IgG titer measurements following an elimination diet based on IgG testing. Future larger clinical trials are necessary to determine the degree to which these findings are generalizable.

National allergy programme had little impact on parent-reported food allergies in children aged 6-7 years.

AIM: The ten-year Finnish national allergy programme was launched in 2008 to lessen the disease and psychological burden of allergy. This study assessed the prevalence of parent-reported food allergies requiring avoidance diets at primary school in children aged six and seven years. METHODS: The cohort comprised 1937 children (51% boys) who started primary school in Tampere, Finland, in August 2016. School health nurses charted parent-reported, doctor-diagnosed food allergies requiring avoidance diets as part of the routine health examination. RESULTS: We found that 127 (6.6%) children had parent-reported, doctor-diagnosed allergies to at least one food and 37 (1.9%) were allergic to basic foods, namely cows' milk, wheat and one other grain. All required an avoidance diet. The figure did not differ significantly from the 2.7% and 2.5% found by studies of this age group in 2009 and 2013, respectively. Allergies to fresh fruit and vegetables decreased from 5.8% in 2009 to 3.6% in 2016. CONCLUSION: We studied the national allergy programme that started in 2008 and found that there was a nonsignificant overall decrease in the number of children aged six to seven years on avoidance diets for allergies between 2009 and 2016. The only allergies that showed significant decreases were fresh fruit and vegetables.

Milk basic protein supplementation exerts an anti-inflammatory effect in a food-allergic enteropathy model mouse.

To examine novel functions of milk basic protein (MBP) in T-cell-related inflammatory diseases, such as autoimmune diseases and allergies, we evaluated the effects of MBP on the causative responses of ovalbumin (OVA)-specific T cells in a food-allergic enteropathy model, OVA23-3 mice, which express an OVA-specific T-cell receptor gene. The OVA-specific CD4+ T cells of the mesenteric lymph nodes (MLN) from OVA23-3 mice were cultured with CD11c+ dendritic cells of MLN from BALB/cA mice in the absence or presence of MBP following stimulation with OVA; then the levels of CD69 expression and the levels of cytokine production by CD4+ T cells were measured to evaluate activation. The effects of MBP supplementation of OVA 23-3 mice were assessed by feeding a diet containing OVA (OVA diet) with or without MBP for 28 d. Intestinal inflammation, together with activation and cytokine production of CD4+ T cells by MLN, as well as femoral bone mineral density, were measured. In in vitro culture, MBP inhibited excess activation and IL-4 production by CD4+ T cells. The supplementation of MBP to the OVA diet attenuated OVA-specific IgE production in OVA-diet-fed OVA23-3 mice and slightly resolved developing enteropathy caused by excess IL-4 production by CD4+ T cells. Feeding OVA diet to OVA23-3 mice exhibited bone loss accompanied with enteropathy, whereas MBP supplementation prevented bone loss and increased osteoprotegerin, an osteoclastogenesis inhibitory factor, in the mice. The inhibition of T-cell-activation in both MLN and bone marrow by MBP supplementation may help prevent increased IgE levels caused by excessive IL-4 production and bone loss accompanied by enteropathy. Our findings show that MBP may help attenuate both T-cell-related inflammation and bone loss.

The Role of Elimination Diets in Atopic Dermatitis-A Comprehensive Review.

BACKGROUND/OBJECTIVES: Diet is a common concern for individuals with atopic dermatitis (AD) and their families. Studies regarding the effect of dietary interventions on AD exist, but many are limited by small size and poor design. Conflicting results present a challenge to clinicians seeking to counsel patients. The aim of the current review is to examine the published literature and generate helpful conclusions for clinicians faced with dietary questions in AD. METHODS: A PubMed search was performed focusing on dietary interventions for AD in children and adults through July 2016. The search was limited to the English language and included studies that evaluated one or more forms of dietary modification for the treatment of AD. Studies of supplementation, such as with vitamins, minerals, or probiotics, were not included, nor were studies on prevention of the development of AD. A total of 43 articles met the inclusion criteria and were included in the final analysis. RESULTS: Trials varied in type, duration, and the AD patient populations studied. Overall, there is some level I evidence to support specific exclusion diets in preselected patients but insufficient evidence for strict elimination diets (diets that are typically limited to six to eight foods). Data supporting other interventions are mixed and based on small, poorly designed studies. CONCLUSIONS: A comprehensive literature review reveals some promising results and several areas in need of further study. More evidence is needed to form a strong foundation for recommendations regarding the utility and role of elimination diets in AD management, but current evidence suggests that strict diet management is not effective in the treatment AD in the vast majority of patients.

Nutrition and Allergic Diseases.

The development of IgE-mediated allergic diseases is influenced by many factors, including genetic and environmental factors such as pollution and farming, but also by nutrition. In the last decade, substantial progress has been made in our understanding of the impact that nutrition can have on allergic diseases. Many studies have addressed the effect of breastfeeding, pre-, pro- and synbiotics, vitamins and minerals, fiber, fruit and vegetables, cow's milk, and n-3 fatty acids, on the development of allergies. In addition, nutrition can also have indirect effects on allergic sensitization. This includes the diet of pregnant and breastfeeding women, which influences intrauterine development, as well as breastmilk composition. These include the diet of pregnant and breastfeeding women that influences intrauterine development as well as breastmilk composition, effects of food processing that may enhance allergenicity of foods, and effects via modulation of the intestinal microbiota and their metabolites. This editorial review provides a brief overview of recent developments related to nutrition and the development and management of allergic diseases.

Modifying the infant's diet to prevent food allergy.

Recommendations and guidelines on the prevention of food allergy have changed in recent decades. The aim of this review of the current evidence and ongoing studies is to provide a comprehensive and up to date picture of prevention of food allergy for healthcare professionals. The review was undertaken as part of the European Union funded Integrated Approaches to Food Allergy and Allergen Management (iFAAM) study. This is a wide ranging project bringing together expertise across the breadth of food allergy research. Specifically, the review discusses dietary manipulation in food allergy prevention, and covers the possible preventive strategies of allergen avoidance, early allergen introduction, general nutrition and supplements, as well as other strategies, such as prebiotics and probiotics. The review concludes that despite agreement that allergen avoidance strategies should not be undertaken for allergy prevention, there is currently no consensus regarding what actions should be recommended beyond exclusive breastfeeding for the first 4-6 months of life. Recent and upcoming trial results, which are detailed in this review, should help inform the debate and add clarity to the topic.

Resolution of Allergic Rhinitis and Reactive Bronchospasm With Supplements and Food-specific Immunoglobulin G Elimination: A Case Report.

Context • Allergies are a common affliction, whether they are respiratory, food related, or dermatological. People often resort to continuous use of over-the-counter medications, such as antihistamines, to manage their symptoms. Controversy still remains over testing serum immunoglobulin (Ig) G to diagnose food allergies. Objective • This study intended to examine the benefits of treatment of a pediatric patient with natural supplements and an elimination diet for IgG food allergies. Design • The research team reported a case study. Setting • The study was conducted at Southwest Naturopathic Medical Center (Tempe, AZ, USA). Participant • The participant was a 10-y-old Caucasian female who had diagnoses of allergic rhinitis and reactive bronchospasm, the second of which was exacerbated by allergens such as wheat, perfumes, and seasonal flora. Intervention • Following testing for IgE- and IgG-reactive foods, the patient was treated with natural supplements to reduce her allergic responses and was instructed to make dietary changes to eliminate the IgG-reactive foods. Outcome Measures • The patient's symptom severity was tracked starting 1 mo after her initial visit to Southwest Naturopathic Medical Center. The severity was based on the patient's subjective reports about her congestion to her mother and on her mother's observations of the effect of symptoms on her attention and school performance. The bronchospasm severity was based on the frequency of a sensation of wheezing and chest tightness, the frequency of inhaler use, and the occurrence of any exacerbation of symptoms with acute respiratory illness Results • After 1 mo, in which the patient used the natural supplements, she experienced a 90% improvement in coughing; a 70% improvement in nasal congestion; less chest tightness; and no need for use of loratadine, diphenhydramine, or albuterol. At the 8-mo follow-up visit, her nasal congestion was reported to be entirely gone. Conclusions • The case demonstrates the effectiveness of natural supplements and a diet eliminating IgG-reactive foods in the treatment and management of pediatric allergic rhinitis and reactive bronchospasm.

Children with atopic dermatitis in Daejeon, Korea: individualized nutrition intervention for disease severity and nutritional status.

BACKGROUND AND OBJECTIVES: Atopic dermatitis is one of the most common pediatric chronic inflammatory skin diseases, and certain food allergens and nutrients are closely related to the development and severity of atopic dermatitis. While avoidance of the causative foods is considered the mainstay of treatment, unverified excessive restriction might induce unnecessary limitations in the food intake, consequently leading to nutritional deficiencies and poor growth. This study aimed to identify the characteristics and nutrient intake status in children with atopic dermatitis and to investigate the effects of individualized nutrition intervention. METHODS AND STUDY DESIGN: We retrospectively reviewed electronic medical records of 77 pediatric patients with atopic dermatitis who received 4 months of individualized nutrition intervention combined with an elimination diet. The patient characteristics, nutrient intake status, and clinical status were examined before and after the intervention. RESULTS: Before the intervention, 5 children had a weight for height z-score below -2.0, and 48.1% had experienced food restriction; these children showed a significantly higher SCORing of Atopic Dermatitis index than those without experiences, with the number of restricted foods before the intervention positively correlating with the disease severity. The intakes of n-6 and n-3 fatty acids, calcium, folate, and vitamin D were lower than the recommended nutrient intakes for Koreans. After the intervention, the weight for height z-score of 35 children was significantly increased and their SCORing of Atopic Dermatitis index was significantly reduced (p<0.05). CONCLUSIONS: Individualized nutrition intervention appears useful for alleviating the severity of atopic dermatitis and improving the growth status by improving the nutrient intake.

An unexpected cause of anaphylaxis: potato.

Immediate reactions against contact to raw potato has been reported in adults with generally being in the form of an oral contact dermatitis or contact urticaria, but it may also manifest as rhinitis symptoms, wheezing or even anaphylaxis. Cooked or raw potato allergy has been rarely reported in children as some is being immediate and others being late reactions, and it usually results from ingestion. Herein, we report two cases with a background of allergic diseases developed anaphylaxis one with cooked potato and the other one with raw potato.

[Dietary management of food allergies]. / Ernährungstherapie bei Nahrungsmittelallergien.

A therapeutic diet is only indicated if the diagnosis of food allergy is certain. In the case of an unproven suspicion everything should be done to confirm or disprove the diagnosis by diagnostic measures (patient history, diet history, food and symptom protocol etc.). In the case of proven food allergy there are different aims of nutritional therapy. Most importantly the patient should learn how to identify his eliciting agent in pre-packed and non-prepacked food and how to avoid it. The elimination diet should take into account the individual condition of the patient. In particular, if basic foods have to be eliminated from the diet, safe alternatives have to be determined to maintain a nutritionally balanced diet and to maintain a high quality of life. To ensure the nutritional adequacy of the diet, micro- and macronutrient intake should be analysed and improved, if necessary. For pollen-associated food allergy and certain chronic conditions it might be necessary to be aware of possible triggering factors as well as potential cross-reactions. Moreover, individual tolerance should be maintained during elimination diets and not jeopardized by voluntary and unnecessary self-denial of certain foods.An effective individual management of food allergies by the patient is considerably dependent on the quality of the nutritional education and therapy.

Probiotic Dahi containing Lactobacillus acidophilus and Bifidobacterium bifidum modulates immunoglobulin levels and cytokines expression in whey proteins sensitised mice.

BACKGROUND: Cow milk allergy is the most common food allergy in children. So far, no effective treatment is available to prevent or cure food allergy. This study investigated whether orally administrated probiotics could suppress sensitisation in whey proteins (WP)-induced allergy mouse model. Two types of probiotic Dahi were prepared by co-culturing Dahi bacteria (Lactococcus lactis ssp. cremoris NCDC-86 and Lactococcus lactis ssp. lactis biovar diacetylactis NCDC-60) along with selected strain of Lactobacillus acidophilus LaVK2 and Bifidobacterium bifidum BbVK3. Mice were fed with probiotic Dahi (La-Dahi and LaBb-Dahi) from 7 days before sensitisation with WP, respectively, in addition to milk protein-free basal diet, and control group received no supplements. RESULTS: Feeding of probiotic Dahi suppressed the elevation of whey proteins-specific IgE and IgG response of WP-sensitised mice. In addition, sIgA levels were significantly (P < 0.001) increased in intestinal fluid collected from mice fed with La-Dahi. Production of T helper (Th)-1 cell-specific cytokines, i.e. interferon-γ (IFN-γ), interleukin (IL)-12, and IL-10 increased, while Th2-specific cytokines, i.e. IL-4 decreased in the supernatant of cultured splenocytes collected from mice fed with probiotic Dahi as compared to the other groups. Moreover, the splenic mRNA levels of IFN-γ, interleukin-10 were found to be significantly increased, while that of IL-4 decreased significantly in La-Dahi groups, as compared to control groups. CONCLUSION: Results of the present study indicate that probiotic Dahi skewed Th2-specific immune response towards Th1-specific response and suppressed IgE in serum. Collectively, this study shows the potential use of probiotics intervention in reducing the allergic response to whey proteins in mice. © 2015 Society of Chemical Industry.

In vitro evidence for efficacy in food intolerance for the multispecies probiotic formulation Ecologic® Tolerance (Syngut™).

The beneficial effects of probiotics are currently the subject of extensive studies in health and medical research. The aim of this research was to specifically design a new probiotic formulation for supplementation in people suffering from food intolerance. The selection of strains was focussed on the capacity to influence mechanisms of action that are important in development of food intolerance with the following parameters measure: in vitro capacity to produce ß-galactosidase, in vitro strengthening of the epithelial barrier, in vitro stimulation of cytokines produced by regulatory T cells, in addition to assessing fundamental quality criteria (stability, gastrointestinal (GI)-survival, multispecies concept, allergen-free). Ecologic®Tolerance/Syngut™ was subsequently developed consisting of a multispecies concept using 4 different probiotic strains (Bifidobacterium lactis W51, Lactobacillus acidophilus W22, Lactobacillus plantarum W21 and Lactococcus lactis W19). Each of these strains demonstrated ability to survive the GI-tract and strain specific effects in producing ß-galactosidase, strengthening the gut barrier function after immunological-induced stress and inhibiting Th2 cytokines (IL-4, IL-5 and IL-13 (≥50%), in addition to stimulating interleukin-10 levels; thus, providing in vitro evidence for the efficacy of the selected strains to provide beneficial effects in patients suffering from food intolerance.

Down syndrome--genetic and nutritional aspects of accompanying disorders.

Down syndrome (DS) is one of the more commonly occurring genetic disorders, where mental retardation is combined with nutritional diseases. It is caused by having a third copy of chromosome 21, and there exist 3 forms; Simple Trisomy 21, Translocation Trisomy and Mosaic Trisomy. Symptoms include intellectual disability/mental retardation, early onset of Alzheimer's disease and the appearance of various phenotypic features such as narrow slanted eyes, flat nose and short stature. In addition, there are other health problems throughout the body, consisting in part of cardiac defects and thyroid function abnormalities along with nutritional disorders (ie. overweight, obesity, hypercholesterolemia and deficiencies of vitamins and minerals). Those suffering DS have widespread body frame abnormalities and impaired brain development and function; the latter leading to impaired intellectual development. Many studies indicate excessive or deficient nutrient uptakes associated with making inappropriate foodstuff choices, food intolerance, (eg. celiac disease) or malabsorption. DS persons with overweight or obesity are linked with a slow metabolic rate, abnormal blood leptin concentrations and exhibit low levels of physical activity. Vitamin B group deficiencies and abnormal blood homocysteine levels decrease the rate of intellectual development in DS cases. Zinc deficiencies result in short stature, thyroid function disorders and an increased appetite caused by excessive supplementation. Scientific advances in the research and diagnosis of DS, as well as preventing any associated conditions, have significantly increased life expectancies of those with this genetic disorder. Early dietary interventions by parents or guardians of DS children afford an opportunity for decreasing the risk or delaying some of the DS associated conditions from appearing, thus beneficially impacting on their quality of life.