Pediatric Nutrition in Practice

200 Heine^

Dietary Management of Food Allergy

Treatment of food allergies is based on strict elimi-
nation of specific food proteins until tolerance has
developed [1]. As allergens are commonly dis-
guised in manufactured food products, this in-
volves education of parents and careful reading of
ingredient labels [14]. In non-IgE-mediated food
allergy, due to the diverse spectrum and underlying
mechanisms and the absence of clear diagnostic
markers, it may be difficult to define an exact diag-
nosis. In these children, empirical treatment with
dietary manipulations is common practice. Elimi-
nation diets avoiding multiple food allergens
should be monitored by a pediatric dietician to
safeguard the nutritional adequacy of the diet, and
growth parameters should be carefully monitored.
In breastfed infants, a maternal elimination
diet may be effective as intact food antigens in

breast milk can elicit allergic manifestations in

the infant [9]. The maternal diet should be nor-

malized as soon as tolerated by the infant. An ad-

equate maternal intake of protein and micro-

nutrients needs to be maintained. The maternal

calcium intake recommended for breastfeeding

mothers is 1.2 g per day (provided as separate

portions throughout the day).

Several hypoallergenic formulas are available

for the treatment of infants with cow’s milk and/

or soy allergy who are not breastfed ( table  4 ).

These hypoallergenic formulas are tolerated by at

least 90% of infants with cow’s milk allergy [15].

There are two main types of hydrolyzed formula,

partially and extensively hydrolyzed formulas.

Partially hydrolyzed formulas may have a role in

allergy prevention but are not suitable for infants

with established clinical signs of cow’s milk al-

lergy [16]. Extensively hydrolyzed formulas are

Ta b l e 3. Investigation of food allergy

Clinical presentation Diagnostic test Comments

Immediate-onset reaction
(IgE-mediated)
Urticaria/angioedema
Oral allergy syndrome
Anaphylaxis

Food-specific serum IgE antibody

(ImmunoCAP) or SPT demonstrate evidence of

sensitization

Diagnosis of IgE-mediated food allergy likely if

food-specific serum IgE levels or SPT diameter

above 95% predictive diagnostic decision points

If inconclusive, food challenges in controlled

environment (hospital) are required to confirm

allergy or tolerance

Home challenges may be indicated if SPT or

serum food-specific IgE is negative (requires

supervision by trained allergist)

Delayed-onset reaction
(non-IgE-mediated)
FPIES or proctocolitis

Diagnosis based on symptomatic improvement

within 2–4 weeks after allergen elimination and

relapse on subsequent food challenge

FPIES food challenge generally not performed

before 2 years of age

Gastrointestinal biopsy, as clinically indicated

(mainly for enteropathy; sometimes required in

infantile allergic proctocolitis if atypical

presentation)

Food-specific serum IgE antibody and SPT

negative

Histological appearance of allergic enteropathy

similar to celiac disease

Mixed reaction
(IgE-/non-IgE-mediated)
Atopic dermatitis
Eosinophilic esophagitis

Food-specific serum IgE antibody

(ImmunoCAP) or SPT

Esophageal biopsy in patients with suspected

eosinophilic esophagitis (severe feeding refusal

in infants; gastroesophageal reflux symptoms,

dysphagia or food impaction in older children)

Elimination diet, as guided by history and SPT/

specific IgE testing, and empirical elimination of

non-IgE food allergens (followed by challenge)

Esophageal biopsy reveals increased tissue

eosinophils (>15 eosinophils per high-power

field in upper and lower esophagus)

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 195–202

DOI: 10.1159/000360340