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Admin User replied on

I have three questions:

1) Has anyone ever seen a child or adult with EoE as well as OAS and the EoE symptoms improved on avoidance of birch pollen cross-reactors?

2) Has anyone have experience on elimination diets in adults with EoE - particulalry using Elemental 028 followed by reintroduction of foods - it will be great to know how you decide which foods to reintroduce first.

3) Finally - does anyone have a standarised chart/measure to look at symptom improvement in adults with EoE?

Thanks

Carina Venter

Carina Venter replied on

1.  We do often see OAS in our adolescent and adult patients with EoE.  We typically ask them to avoid the raw version of the food causing symptoms - even if the symptoms are minor. 

2.  Typically, our adults do not opt for elemental diets.  Do you see many adults who would follow an elemental diet?  They would have to be very motivated.  Even though the initial diet on AAF alone is only 8 weeks (give or take), it is still a long road to get to anything that resembles a normal diet with a variety of foods.  

I currently have one adult patient who was prescribed a "modified" elemental diet:  AAF and one other food.  The patient did not feel she could comply with formula alone.  If she has symptomatic and histologic resolution on this diet, we would likely progress the diet based on many factors (with input from allergy, GI, nutrition and the patient):  the allergy evaluation, her past diet (it doesn't make sense to go right back to a diet similar to what she was eating before), her social eating and food needs and her nutritional needs.  We would probably start with lower risk fruits and vegetables and hope for some success to expand the diet as quickly as possible.  The most commonly implicated foods (milk, egg, wheat and soy) would be added last.  I am curious what others are doing.

3. I think a standardized chart to measure symptomatic improvement in adults with EoE would helpful.  We don't have one but I am also curious if anyone is using one.

Marion Groetch

Marion Groetch replied on

There can be an increase on EoE symptoms and eosinophils identified by EGD during pollen season. This is why EGD may be schedule outside of the pollen season on this population.

Food introduction generally occurs with the least allergenic foods and avoiding the most commonly allergenic foods, i.e. milk, wheat, soy, egg. This of course is based on a "case to case" basis.

The Mayo Clinic has an adult questionnaire which has been used at Penn to measure the quality of life in their adult EOE patients. Due to copywrite laws, I am unable to share this questionnaire. Contact Yvonne Romero, MD at the Mayo Clinic for permission to use.

Kathy L. Pinzone

Kathy Pinzone replied on

Hi Carina,

I have seen adults improving on an elimination diet based on birch pollen cross-reactors. I usually design the elimination diet based on targeted eliminations, meaning that the allergy focused diet history is leading for the elimination diet.

I have had patients improving for 75% regarding their EoE symptoms, but I must say, It is only since recent years that we are seeing these patients and still building up my experience.

I do not have a standardised chart/measure (yet) to  look at symptom improvement, unless there is taken biopsies.

Berber Vlieg

Berber Vlieg-Boerstra replied on

I’m a registered dietitian specializing in food allergy/intolerance. Many specialty dietitians are starting to offer video conference counselling, because it allows them to see clients from any location on a flexible schedule. A colleague of mine specializes in diabetes nutrition and provides services to several small clinics that aren’t large enough to employee a dietitian. Is there a need for this type of counselling in food allergy/intolerances? 

Wendy Busse replied on

Dear Wendy,

I think indeed that there is a need for this type of counseling in food allergy. I use vido conference, e.g. by skype, in addition to face to face consulting. This is a good alternative for patients who have to travel quite far, or when I want to see patients after school of in the evenng after work.. However, for extended consulting and for the first appointments, I do not prefer skype, as I want to get familiar with the patient/family through direct contact.

kind regards.

Berber Vlieg, PhD RD

the Netherlands

Berber Vlieg-Boerstra replied on

Of course I follow the guidelines, but I would like to know of more resources/great articles on management of urticaria and angioedema in children.  I often see these types of patients in my clinic.

Thanks!

Maria Crain, CPNP

Maria Crain replied on

I am a dietitian and I am often asked to speak to nutrition or other alllied health professionals on the topic of "Food Allergy."  I find this frustrating because it is difficult to determine what should be covered.  I think a more narrow topic is always easier to cover (e.g., milk allergy or FPIES or EoE) than a broad topic. 

Many practitioners who are not specialists in food allergy need an overview and maybe a brief review of our guidelines.  I typically start by defining what is and what is not considered food allergy, food elimination diets (for diagnostic and treatment purposes), avoidance issues and meeting nutritonal needs on an elimination diet. 

I have another "Food Allergy" talk coming up and I am struggling again. If you were in a general talk on Food Allergy, what would you like to see covered?

 

Marion Groetch replied on

I think the subject of what is appropriate regarding testing and advising patients related to food allergies. Dispelling common myths, and updating on the latest research which dictates the guidelines is often popular in our academic setting.

Sheelagh Stewart replied on

Thanks SHEELSTEW. 

Even though dietitians are not involved in performing or ordering food allergy testing, I do cover that topic because there are many "alternative" (and unvalidated) testing methods that are strongly marketed to the nutrition professionals.  I once did a 12 common food allergy myths talk that was popular with families. That is a good idea for professionals too.  Thanks!

Marion Groetch replied on

This is a great new addition to the website!

In your practices, are you using Zyrtec, Benadryl, or another antihistamine more for oral food challenges? And if you are doing DBPCFC's do you routinely use Zyrtec if they react on the first day, or do you stick with Benadryl?

Thank you!

Jaime Ross replied on

http://allergicliving.com/index.php/2013/12/02/advisory-labels-may-contain-confusion

How do you educate your patients on precautionary labels?  Here is a link to an interesting article published in Allergic Living about a new study by Steve Taylor's group (Food Allergy Research & Resource Program at the University of Nebraska-Lincoln).

I find many of our patients mistakenly believe they can assess the degree of risk based on the type of precautionary label used (may contain vs. manufactured in a facility, etc.) - Dr. Taylor's study and others have dispelled this myth- time to get the word out.

 

Marion Groetch replied on

I find that different allergists make different recommendations.  I do tell families in regards to nuts would avoid products with precautionary labeling especially anything candy or chocolate like.  I find that some families follow this advice but many do not and continue to use products with precautionary labeling.

Does anyone have thought on precautionary labeling for wheat and avoidance or not?

Wendy

Wendy Elverson replied on

When I educate patient families on label reading, I always begin with an overview of what FALCPA covers before going into detail about the specific foods they will be avoiding.  This includes precautionary labeling. (And I do recommend avoidance of all foods with precautionary labels, not just peanut.) Here are the main points I cover on this topic:

  • Precautionary Labels are not required or regulated.
  • Explain the language/words are also not regulated.  I usually give parents an example of 2 products 1 containing "processed in same facility" and another containing "processed on the same equipment".  I ask them to pick which one seems more "scary".  They always pick "processed in the same facility".  I then explain that the products could be processed exactly the same because the manufacturers have the liberty to choose the words they like best. I then finish by reminding them you cannot assess how great the risk is based on the language used on the package. 
  • Recommend avoidance of all products containing a precautionary label (explain research supports this recommendation)
  • If families really want to consume a product that has a cautionary label, I recommend they call the maufacturer and ask for more information regarding the labeling practices. I give examples of specific questions to ask regarding how the item is manufactured.  And last, I always advise parents that if manufacturers are not willing to share their cross contamination practices or only offer very vague answers, to avoid their product. 

I am excited we have additional information to share with families regarding the recommendation of avoiding foods with precautionary labels. 

April Clark

 

April Clark replied on

I'm a Paediatric Dietitian with a special interest in food allergy based in the Republic of Ireland. Food labelling in terms of declaration of ingredients on the label and declaration of allergen content is enshrined in legislation governed by the EU and implemented in each member state.

Precautionary labelling on the other hand is not enshrined by any legislation and as such it represents meaningless information.  Studies done by the Food safety authority of Ireland among others has demonstrated that there is no such concept as "totally free from".  

There is always risk. Risk however can can be mitigated, accepted or rejected by patients provided they are counselled realistically and practically as to meaningful interpretation of ingredients on food labels: this is how I and many other dietitians and clinicians educate our patients with food allergy. In summary the advice is to check the ingredients every time, ignore precautionary labels. No label, no adrenaline-no eat. 

Ruth Charles replied on

I advise my families to avoid their allergens on the label including precautionary labels. I find that that their not reading the label every time they purchase the food is a greater problem causing accidental ingestions.

Lynn Christie replied on

Great discussion! 

Wendy:  I have seen numerous studies on the risk associated with products carrying a precautionary label for peanut, milk, and eggs. To my knowledge, no one has looked at (or at least published) on the risk associated with products precautionary labeled for wheat. I think we can assume there is some risk.

I agree with April’s guidance (above) and I too advise my patients to avoid any product with a precautionary statement for their allergen.

According to a study published in Annals in 2010, a considerable proportion of accidental exposures are attributed to inappropriate labeling (47.8%), failure to read labels (28.6%), and ignoring precautionary statements (8.3%). So while the risk may be small, it is a risk nonetheless and as a dietitian, I can always guide my patients to a similar product without a precautionary label.

(Annals of Allergy, Asthma & Immunology, Volume 104, Issue 1, January 2010, Pages 60–65)

Marion Groetch replied on

The 2014 AAAAI Annual Meeting in San Diego is only a couple weeks away! Registration: https://www2.cmrreg.com/aaai_7a/

The Allied Health Professional Assembly would like to point out some not to miss key sessions (click on the link for a detailed description):

Friday (February 28) Advanced Practice Course - 8:00 am – 12:30 pm (Ticketed and additional payment required for breakout sessions to attend) (https://aaaai.confex.com/aaaai/2014/webprogram/Session4115.html )

Friday (February 28) Allied Health Plenary: Cybersecurity: Technology in Practice      4:00 pm – 5:15 pm
(https://aaaai.confex.com/aaaai/2014/webprogram/Session3300.html )

Saturday (March 1) Allied Health Workshop: Travel Scholarship Award Recipients            2:00 pm – 3:15 pm (https://aaaai.confex.com/aaaai/2014/webprogram/Session3328.html)

Sunday (March 2) Allied Health Oral Abstract Luncheon (Ticketed and payment required) (https://aaaai.confex.com/aaaai/2014/webprogram/Session4190.html)

Monday (March 3) Primer on Primary Immune Deficiency (PIDD) Course                      8:00 am – 2:15 pm (Ticketed and payment required) (https://aaaai.confex.com/aaaai/2014/webprogram/Session3242.html)

In addition to all the fine educational programs there are many opportunities to network:

Friday (February 28) Allied Health Wine & Cheese Reception                                           5:15 pm – 6:30 pm - Open to All Allied Health Attendees Only (Marriott South Tower, Level 4, La Costa)

Saturday (March 1) Allied Health Forum Lunch                                                                12:30 pm – 1:30 pm - Open to All Allied Health Attendees Only (Marriott North Tower, Lobby Level, Marriott Hall Salon 6)
 

Admin User replied on

The 2014 annual meeting in San Diego was a big success in part to the participation of so many of our members. It is a little more than two weeks since we all have returned home and before we all get back into our routines, please take a moment to consider and inform us whether there is a topic you missed hearing about, or a speaker you missed hearing. Thank you for your feedback!

Debra Sedlak replied on

We have a 10 year old admitted with hives, tight throat and wheezing/respiratory distress after albuterol neb and after albuterol inhaler. Has anyone cared for patient with anyphylaxis to albuterol?

Anne Borgmeyer replied on

 

With antibiotic, venom or anesthesia skin testing, which have a greater risk of anaphylaxis, our allergy nurses would have more direct observation/monitoring procedures in place.

Hope this is helpful.

Kathy Pinzone replied on

I have a question about skin test procedures- does your practice require staff performing procedure to remain in room during the wait time after skin test placement? My clinic is looking into this and I can't seem to find a rec policy that specifies a nurse directly observing /monitoring and not just being nearby. Thanks in advance for any info!

Admin User replied on

I work at St. Louis Children's Hospital and we are working on ways to prevent readmission to hospital and return to emergency room after admit/discharge for asthma. Would anyone be willing to share ideas that you have found successful?

Anne Borgmeyer replied on

What are the frequently asked questions from patients about incorporating baked milk and baked egg in the diet after passing a physician supervised food challenge?

We often hear:

Can I bake with butter?  Can my child eat pancakes or waffles even though they are not baked? What about meatballs and egg noodles?

Does your facility have a protocol to answer these questions or are questions answered on an individual basis?

Marion Groetch replied on

We have published a ladder (graded introduciton) of milk products. One of my PhD students are just validation it. You may or may not find it helpful.

We have look at the allergen content and heat exposure of a number of milk containing foods. We found to big a variation in the milk protein content of butter and then not to include it till after the yoghurt phase - but some chidlren tolerate it sooner. Have a look at additional file 2 in the paper which is free to download: http://www.ctajournal.com/content/3/1/23

Carina Venter

Carina Venter replied on

Dear All

 The food allergy group of the British Dietetic Association recommend the following when it comes to "may contain". We have had it peer review on an international level, but practices and guidance may differ from country to country and family to family:

“May contain…” or “Made in a factory…” labelling

 These warnings are used by food manufacturers to highlight a possible risk of an otherwise nut free product being accidentally contaminated by nuts during manufacturing. There is currently no law to say how or when this type of labelling should be used but it appears on a wide variety of products.

 It is important to take these warnings seriously and consider the following points:

  • Just because a particular food with a nut warning has been eaten safely in the past, does not mean that it will always be safe; it may contain nut traces next time. Recipes and manufacturing processes can change.
  • All nut warnings should be treated with the same level of risk regardless of the wording used.
  • Patients may be more sensitive to nut protein if they are unwell, have been doing strenuous exercise or drinking alcohol, so having a nut trace during these times is more risky.
  • Chocolate and chocolate covered items pose a higher risk of nut contamination because chocolate dripping off one product may be used on another during manufacturing. Therefore, chocolate with nut warnings should always be avoided (lists of peanut free or all nut free products are available from chocolate manufacturers).

  The safest approach is to avoid all foods with “may contain” nut warnings. However, if a food with a nut warning is to be eaten the following advice should always be followed:

  1. always have in-date emergency medication to hand
  2. be within easy reach of a phone or mobile that has charge and reception
  3. only eat if someone is with you who can help if a reaction occurs
  4. avoid if in a remote location, far from emergency services
  5. avoid if unwell or asthma is not well controlled
  6. avoid after strenuous exercise or drinking alcohol
  7. avoid if previously had an anaphylactic reaction to nut traces or “may contain” products

 Discuss your approach to managing “may contain nut” products with your Dietitian or allergy team as they can give you specific advice.

Carina Venter

Carina Venter replied on

A local allergist asked me for guidelines to help them identify when they need to make a referral for a nutrition consult. Here is a beginning list. Does anyone else have tool they use and like? :

1. Newly diagnosed with milk food allergy or 2 or more food allergies

2. Poor growth or weight loss - would want to catch before they meet the definition of failure to thrive

3. Parental anxiety to offer new foods or individual eats only a limited number of foods

4. Food allergic individual with any feeding problmes

5. Always need follow-up to ensure alternative food sources are accepted and that the allergens are properly avoided.

Lynn Christie replied on

How about

When introducing complementary foods in infancy with FPIES.

and

For any patient on an elimation diet for EoE.

Marion Groetch replied on

Soy infant formula has been used as a replacement for cows' milk formula since the early 1900s. The American Academy of Pediatrics (AAP) states that soy formulas are safe and effective for older infants (after 6 months of age) and current research shows no hormonal effects in long-term feeding of soy formulas. The AAP found that although soy has been studied by numerous investigators in various species, "there is no conclusive evidence from animal and adult human or infant populations that dietary soy isoflavones may adversely affect human development, reproduction, or endocrine function."

Nonetheless, if you google soy and phytoestragens, you will see the chatter about the negative effects of soy.  Patients frequently ask if soy is safe as a substitute for milk. I give a recap of the above and if parents are still concerned I help them use a variety of foods to meet their child's needs, but most of the other milk substitutes alone are not sufficient (either too low in fat or protein).

How are you all handling the soy question?

Marion Groetch replied on

I handle the soy question very simiarly to what you proposed. I have a chart that shows the differences in fat and protein between a few milk alternatives to illustrate the signifcant challenge in meeting protein needs using a milk alternative. We also discuss the age of the patient and the acceptibility of the other protein and fat sources.  I have found acceptance of meat to be lower in multiple food allergy patients that have not had assistance with feeding skill progression (from parents or health care provider).  WIth each patient, I take a 24 hour recall, it helps me and the parents to understand potential nutrient deficiets and may give some wiggle room to soy acceptance. If not, I put on my creative thinking cap and work around soy in the diet. 

Raquel Durban replied on

I am interested in what strategies are being utilized for smoking cessation, within rural areas. Particularly what innovative ideas address transportation issues, or distance as a barrier.What ideas have proven successful or not?

Sheelagh Stewart replied on

With back to school time  upon us in many areas, I am wondering if a greater awareness in food allergy and asthma care among school staffers has been noticed.  As many of us work with school nurses and other school staff, I am wondering if positive changes in comfort level of staff is observed by parents and care providers.

Sally Noone replied on

I am not sure if you have seen this, but I think it is a great 30 minute free school food allergy training module for schools that is followed by a short competency quiz. These tools and resources were designed to assist school nurses or their designees in school wide food allergy education and in the implementation of the new CDC Food Allergy Guidelines. I am not a nurse so I am very curious what the nurses think of this module.
 

Check it out:  http://www.allergyhome.org/schools/

Marion

Marion Groetch replied on

I have developed several school nurse presentations but this one seems to be very thorough and something I would like to use in the future.  I especially like how they cover different ways food allergy exposure can occur.  I find that school nurses are often anxious with contact and inhalation issues and this presentation really covers it all.  Thanks for the share, Marion.

Maria Crain replied on

Thank you for sharing this module, Marion. It is excellent!

I am a nurse, interested in providing asthma and allergy training to school nurses. This module covers everything, including psycological and bullinging issues. It is up to date, evidence-based, well-referenced information. School nurses can easily access it, take the follow up competency quiz and print their certificate to verify completion.

I would highly recommend this video to anyone interested, HCPs, parents, even students. It clarifies those questions and concerns that need to be addressed.

Dee Mallam RN, AE-C

Dee Mallam replied on

Have any pending speaking questions about the 2015 AAAAI Annual Meeting? A recommended read is the 2015 AAAAI Annual Meeting Information page in the news feed.

Admin User replied on

We have seen record numbers of patients in the EU, inpatient area and PICU of our children's hospital with viral triggered asthma. Enterovirus is suspected although the multiplex swab results are positive for Rhinovirus/Enterovirus. We are treating per usual asthma protocol. Has anyone tried or heard of any novel treatments for this population?

Anne Borgmeyer replied on

I error on the side of caution and maybe to a fault as I am concerned that precautionary labels are not standardized as Carina Venter, PhD pointed out in a different thread. My concern is that the precautionary cross contamination labels to not indicate to what full extent the food may or may not have been contaminated and legislation is not in place to validate these claims. With non-IgE mediated allergies, I advise against foods with allergen cross contamination labeling as I also believe that if there is an allergen present repeated exposure to that protein could be harmful.

Raquel Durban replied on

We are looking at our asthma protocol regarding steroid dosing for asthma. We currently use 2mg/kg/per day up to 60mg X 5 days. Would like to hear what others are doing. The literature is not clear.

Anne Borgmeyer replied on

At MGH pediatric allergy we generally use 2mg/kg max of 50mg and generally for 5 days.  Many of the providers prescribe a dose of 40mg x 5 days.  

Elisabeth Stieb replied on

I'm curious if anyone uses dietary therapy for EG and/or EGE.  If so, has anyone seen success using the common dietary therapies used for EoE in these other disorders?  Or have you recommended them but have not been able to track effectiveness?  Just wanted input on what others are doing as we sometimes see these patients in clinic and I feel like we have very little options or support to offer them. Please share your thoughts or experiences.  Thanks!

April Clark replied on

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