1. Accommodating and Educating Students with Food Allergy
Marion Groetch, MS, RD
Director, Nutrition Services
Jaffe Food Allergy Institute
Mount Sinai School of Medicine
New York, New York

2. Learning Objectives
Define the difference between food allergy and food intolerance.
Describe the steps involved in the allergy evaluation.
Acquire the skills and identify resources to provide comprehensive education for allergen elimination diets.
Understand the nutritional risks of allergen elimination diets.
Identify resources for Job Corps food service staff, nurses and center personnel.
Groetch 2011

3. Guidelines for the Diagnosis and Management of FA in the US: NIAID-Sponsored Expert Panel Report
Based on comprehensive review and objective evaluation of the recent scientific and clinical literature on FA.
Working with more than 30 professional organizations, federal agencies and patient advocacy groups led the development of “best practice” clinical guidelines.
43 distinct recommendations
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

4. Definition of Food Allergy (FA)
An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food
Food intolerance
An untoward response to food substance that is not immunologically mediated
hives after ingestion of egg, throat tightness after ingestion of peanuts, severe vomiting after milk ingestion

5. Food Allergies Can Be Life-Threatening
More people die each year from food allergy-induced reactions than to reactions to insect stings.
Food allergy is believed to cause an estimated 30,000 emergency department visits each year in the US.
The potential severity of a food allergic reaction cannot be predicted. Once a reaction begins, there is no way of predicting how severe it may become.

6. Anaphylaxis
Allergic reaction that occurs most commonly within minutes (but can be up to several hours) after contact with an allergy causing substance.
A serious allergic reaction that is rapid in onset and may cause death.
Epinephrine is the first line treatment in all cases of anaphylaxis.
In other words, anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. When we talk about anaphylaxis we are talking about a severe reaction that generally affects two or more organ systems. In other words the reaction has become systemic.
Biphasic reaction- Initial symptoms of anaphylaxis may resolve only to return later- up to 4 hours. Patients who have experienced an anaphylactic reaction should be followed in the ED for 4 hours after the initial reaction.

8. Food Allergy Immunologic Non-Immunoglobulin E Mediated
Cell-Mediated
Immunoglobulin E (IgE)
-Mediated
(most common)
Anaphylaxis
Oral Allergy Syndrome
Immediate gastrointestinal allergy
Asthma/rhinitis
Urticaria
Morbilliform rashes and flushing
Contact urticaria
Protein-Induced Enterocolitis
Protein-Induced Enteropathy
Allergic proctitis
Dermatitis herpetiformis
Contact dermatitis
Eosinophilic esophagitis
Eosinophilic gastritis
Eosinophilic gastroenteritis
Atopic dermatitis
In contrast to food intolerance, food allergy defines adverse reactions to food protein mediated by the immune system. Food allergy can be further divided into those allergies that are mediated by IgE antibody and those which are not IgE mediated. The IgE mediated food allergies are typically acute in onset and examples include anaphylaxis or urticaria. The non-IgE mediated food allergies are generally slower in onset and primarily are gastrointestinal reactions.
Sampson H. J Allergy Clin Immunol 2004;113:805-9, Chapman J et al. Ann Allergy Asthma & Immunol 2006;96:S51-68.

9. Diagnosis of IgE-Mediated Food Allergy
Role of the primary care physician or Board Certified Allergist
Detailed medical and dietary history with a focus on symptoms
Identify general approach
Allergy vs. intolerance
IgE vs. non-IgE
Thorough physical exam
Diagnostic tests to rule out other medical conditions not related to food allergy
If you see a patient who you suspect has a food allergy, refer to a board certified allergist. Undiagnosed allergies can be dangerous. On the other hand, unnecessary avoidance diets create nutritional challenges and often lead to diets that are nutritional inadequate.
Dietitian may support allergist in obtaining dietary history or assist patients in keeping food/symptom records.

10. Food Allergy Testing—IgE
Prick Skin Test (PST)—IgE
Serum IgE–(CAP–System FEIA) Quantitative measurement of food specific IgE
Double Blind Placebo Controlled Food Challenge- Considered “Gold Standard” for FA diagnosis
Atopy patch testing- some facilities are beginning to use APT to test for non-IgE mediated allergies, but as of now, the reagents for patch testing are not standardized and results can be variable.
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

11. Food Allergy Guidelines
Serum IgE or PST may be used to identify foods that potentially provoke IgE-mediated food induced allergic reactions, but alone, these tests are not diagnostic.
The expert panel does not recommend routine screening for food allergy.
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

12. Severity of Food Allergy
The severity of a potential allergic reaction can not be predicted by IgE level or by size of a PST.
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

13. Dietary Manipulation as a Diagnostic Tool
The food allergy guidelines suggests elimination of one or few specific foods to make the diagnosis of FA, especially in non-IgE medicated food allergic disorders.
Useful when chronic symptoms or delayed symptoms make determining the cause difficult.
Removal of the suspected allergen with anticipated significant improvement or remission of symptoms.
The avoidance diet will be the same for diagnostic purposes or for therapeutic purposes. .
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

14. Disorders Not Proven to be Related to Food Allergy
Migraines
Behavioral / Developmental disorders
Arthritis
Seizures
Inflammatory bowel disease
A number of disorders have been unscientifically linked to food allergy or to adverse reactions to foods. These disorders include migraines, behavioral or developmental disorders, arthritis, seizures, and inflammatory bowel disease among others. No studies have conclusively identified food allergy as a cause for these disorders.

15. Unproven Diagnostic Tests
Basophil histamine release/activation
Lymphocyte stimulation
Facial thermography
Gastric juice analysis
Endoscopic allergen provocation
Hair analysis
Applied kinesiology
Provocation neutralization
Allergen-specific IgG4
Cytotoxicity assays
Electrodermal test (Vega)
Mediator Release assay (LEAP)
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol

16. Education and Training: Avoidance
The food allergy guidelines suggest providing education and training to all individuals with documented food allergy on how to recognize labeling of food allergens on food labels.
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states:
Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58

17. Avoidance Avoidance sheets Reading food labels
Understanding cross contact in manufacturing
Understanding cross contact in restaurant, food service or home kitchen
Minor ingredients
and

18. Label Reading
Read the entire product label each and every time an item is purchased.
And then the crux of any elimination diet…avoidance. Label reading is integral to the success of any elimination diet.
Review 8 major food allergens- The specific tree nuts and the specific fish and crustacean shellfish must be listed on the label.
For example, if casein is an ingredient in the product, the word milk must also be on the product label.

19. Label Reading Food Allergen Labeling Consumer Protection Act (FALCPA)
Milk
Egg
Wheat
Soy
Peanut
Tree nut*
Fish*
Crustacean shellfish*
*Specific species must be listed
"Food allergen labeling consumer protection act”
These eight foods are considered the “major allergens” by the FDA.
Applies to products manufactured in the US but also products imported for sale in the US must follow the same regulations. FALCPA applies to products regulated by FDA not USDA- fresh meat products and fruits and vegetables are not covered by these laws. Major allergens in the EU include these, but also, Sulphites, sesame, mustard, celery and not just wheat but gluten.

20. Incidental Ingredients
A “major food allergen” may not be omitted from the product label even if it is only a minor ingredient.
Allergens not considered “major” may remain unidentified on product labels.
For instance garlic or corn could be a hidden, unidentified ingredient in a flavoring or spice or modified food starch.

21. Cross-Contact
Cross contact occurs when safe foods come in contact with an allergen, causing the safe food to contain small amounts of unintentional allergenic ingredients.
Information that may or may not be indicated on the product label relates to cross contact risk.
Some sensitive individuals may react to as little as 1 mg of milk, egg or peanut.
It is well known that those with FA occasionally experience allergic reactions from eating packaged food containing undeclared residues of allergens. .
Cross contact may occur in manufacturing, restaurants as well as in the home.

22. Cross Contact Precautionary labeling such as Voluntary and unregulated
May contain…
Manufactured in a facility…
Manufactured on shared equipment…
Voluntary and unregulated
In the US, More and more manufacturers are addressing the issue of unintentional ingredients in their products with advisory statements.
Overall, 7% of the 179 different packaged foods bearing advisory labeling contained detectable peanut protein.
Healthcare professionals need to continue to advise those with food allergies to avoid products with advisory statements.

23. The Amount of Allergen in Products Assessed
7/68
3/57
Hefle et al JACI 2007
But the amount of allergen in the products assessed did not match the perceived risk! More
products with “shared facility statements” had detectable allergen than those with “May contain statements”. As these statements are unregulated we cannot assign a risk value to various advisory statements
We need to counsel consumers to avoid products that may contain their allergen
2/51
% of products with detectable allergen
Overall 7% of all products (n=179) with advisory statements tested contained detectable allergen residue.
With permission, Scott Sicherer, MD 23

24. Risk Associated with Milk Advisory Statements
Overall milk was detected in 36% of products (n=147) with milk advisory statements
Dark chocolate had the highest % with detectable milk in 82% of samples with milk advisory statements.
Milk concentrations ranged from 3.4 ppm-4,800 ppm. O mg milk protein. There was no relationship evident between the type of advisory statement and the level of milk contamination.
SO let’s remember that advisory statements at this time are voluntary and unregulated and we should avoid products with and advisory statement for our allergen.
Crotty JACI 2010 24

25. Food Allergy Guidelines
NIAID guidelines suggest avoiding any product that has any advisory statement for your allergen.
Two things to keep in mind. When it comes to avoidance for IgE mediated allergies, there is no evidence that strict avoidance will help a patient become tolerant sooner…as a matter of fact, there is emerging evidence to the contrary. But we do know that there are some families who require strict avoidance for safety as their allergies are that sensitive. Additionally, it is our belief that the EoE patient with non-IgE mediated allergies is more sensitive. Keep in mind that the vast majority of patients with IgE mediated milk allergy tolerate eHF…more than 90% but these formulas are not tolerated by those with EoE and milk allergy.
Boyce JA, Assa'ad A, Burks AW, et al. JACI 2010.

26. Label Reading Summary
Read product labels each and every time an item is purchased.
Look at the ingredient list and precautionary labels.
Avoid products that have a precautionary statement for your allergens.
May need to call manufacturers for additional product information.

27. Food Service
Managers should conduct food allergy training and review of the food allergy management plan periodically to be sure that both new hires and existing employees are properly trained.
Employees should understand how cross-contact can occur.
The food service establishment should have at least one person on duty, ideally the manager, who can handle questions and special requests from students with food allergies.
Groetch 2011

28. Food Service
Other staff members should know who the food allergy manager is and should always direct questions about food allergies to that person.
A cafeteria should be able to supply, upon request, a list of ingredients for a menu item.
If a mistake occurs with an item prepared for a student with a food allergy, the only acceptable way to correct the situation is to have the kitchen staff discard the incorrect item and remake it.
If a student is having an allergic reaction, call 911 and get medical help immediately!
Groetch 2011

29. Cross-Contact in the Cafeteria
Consider anything used for more than one food and not cleaned completely!
Utensils, dishes
Cutting boards
Grinders, blenders
Hands
Gloves (no latex)
Processors
Salad bars
Pots, pans
Fryers
Grills
etc., etc...
In addition to reading labels and knowing that the product does not contain an allergen, it is important to know how to prevent cross contact during food preparation.

30. Cross Contact Problem Solution
Allergen-free foods may come in contact with an allergen in storage, in the refrigerator or the cupboard.
Solution
Designate a separate shelf in the refrigerator and cupboard for allergen-free foods. This shelf should be above the shelf that may store foods with potential allergens. Consider using stickers to identify “safe” foods.
Groetch 2011

31. Cross Contact
Problem
A knife used to spread peanut butter may also be dipped in the jelly jar, tainting the jelly with peanut protein.
Solution
Keep a separate jelly jar for the students with allergies. Use clean knives in jelly first.
Preparing an allergen (chopping walnuts on a counter surface) and then a safe food (slicing tomatoes) without properly cleaning.
Prepare the allergen safe food first. Clean cooking equipment including the cooking area with hot soapy water.

32. Cross Contact Problem Solution
Plain French fries are fried in a deep fat fryer that was used to fry onion rings (containing milk, egg, and wheat).
Solution
Fry allergen-free foods separately in clean oil or in a dedicated fryer.

33. Cross Contact Problem Solution
Cafeteria lines and buffets may have greater risk of cross contact due to shared utensils and spills.
Solution
Keep the allergen-safe food completely separate to prevent cross contact.
Groetch 2011

34. To Avoid or Not to Avoid Minor ingredients and cross reactive proteins

35. To Avoid or Not to Avoid A patient with corn allergy?
Corn oil or corn syrup?
A patient with soy allergy?
Soy oil or soy lecithin?
A patient with peanut allergy?
Peanut oil?
Crevel, Kerkhoff, Konig. Allergenicity of refined vegetable oils. Food and Chemical Toxicology. 2000;38:

36. To Avoid or Not to Avoid A patient with sesame allergy?
Sesame oil?
A patient with egg allergy?
Egg white or egg yolk?
A patient with peanut allergy?
Tree nuts or other Legumes?
What about sunflower seed oil?
Sicherer SH. Clinical implications of cross-reactive food allergens. JACI 2001;108:

37.
Every student with a
food allergy should
have an Emergency
Treatment plan signed
by their MD.

38. It Takes a Team
Student/ Health and Wellness Center /Cafeteria/ Center personnel
Student informs Health and Wellness Center and the Cafeteria of the food allergy
Health and Wellness Center ensures the student has an Emergency Treatment plan signed by MD
Health and Wellness Center and Cafeteria communicate information about student’s allergy
Keeping the student with allergies safe is not just the job of the cafeteria personnel. ….all need to communicate with each other.

39. It Takes a Team: Cafeteria
Strict Avoidance – one bite can hurt
Know ingredients/Know the student with allergies
Read all labels – contact manufacturers
Store ingredients to prevent cross contact
Use clean utensils, cooking areas and cooking equipment
May consider a designated area for prep of allergen-free foods.
Prepare allergen free foods first, cover and remove from cooking area
Serve separately – not from cafeteria line
Cross contact can occur in the home kitchen as well as in manufacturing
Some families create separate storage shelves or use a sticker system to identify safe foods.

40. It Takes a Team Assure correct personnel are identified
Identify those trained in food prep for the students with allergies
Identify those trained to answer questions about ingredients and food prep methods
Identify those who will enact emergency action in the event of a reaction
Identify JC center environments that might pose a risk and create procedures to reduce risk
If a reaction occurs, activate emergency action promptly
This ideally should be everyone. Its best if one person on duty is always available to answer questions regarding food ingredients, risks and preparation methods. Who will administer epi-if that is the nurse, then who will call the nurse (consider how long it may take for the nurse to arrice), who will call 911, and so on

41. 3 R’s of an Anaphylaxis Plan
Recognize the symptoms early
React quickly-provide appropriate medication, call 911
Review what caused the reaction
***Every center should have a plan for managing food allergies

42. Treatment of Food Anaphylaxis
Intramuscular epinephrine—EpiPen or Twinject
Prompt administration is key to surviving anaphylaxis. Fatalities have resulted from a delay/failure to give epinephrine.
Follow up in the ED or call 911
4-hour observation period

43. Nutrition Counseling
Food Allergy Guidelines recommends all children with food allergy receive nutrition counseling and close growth monitoring.
In recognition of the nutritional risks and the nutritional contribution of milk in the diet, the exert panel recommends
This is especially important prior to weaning from breast/bottle to alternative milk beverages
Boyce et al. Guidelines for the diagnosis and management of foods allergy in the US. JACI 2010

44. Children with multiple food allergies or cow’s milk allergy are at increased risk of…
Macronutrient/Micronutrient deficiencies or imbalance
Shorter stature
Failure to thrive
Nutritional Rickets/kwashiorkor/marasmus
Christie L, et al. J Am Diet Assoc. 2002;102:1648–1651.
Henriksen C, et al. Acta Paediatr. 2000;89:272–278.
Isolauri E, et al. J Pediatr. 1998;132:1004–1009. 
Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569. 
Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499. 
Flammarion et al. Pediatr Allergy Immunol ; 22:

45. Cow’s Milk Allergy
Foods to avoid: milk, butter, cheese, yogurt, custard, ice cream, puddings…as well as numerous manufactured products such as many margarines, breads, cookies, cakes, chewing gum, cold cuts, crackers, cereals, non-dairy products, processed and canned meats and many frozen and refrigerated soy products
Milk allergy usually begins in infancy and affects 2-3 % of infants. Avoiding milk is not an easy task. If education ends at avoidance, the patient will likely suffer from nutritional inadequacies. You can see that even avoiding one food such as milk can pose a challenge- although milk and wheat avoidance are the most difficult due to the shear number of foods in our processed food supply that contain milk and wheat ingredients. If nutrient rich substitutes are not provided, inadequacies will likely occur.

46. Nutritional Contribution of CM
Calcium
Vitamin D
Vitamin A
Vitamin B12
Riboflavin
Pantothenic acid
Phosphorous
Protein and fat

47. Comparison of CM Substitutes
CM or
CM subs.
KCAL/
8 oz.
PRO g
FAT g
Ca mg/
Vit.D IU CM
150 8
300 / 100
Soy enriched
100 7 4
350 / 100
Oat enriched
120 3
Hemp enriched
2-4 6
400 / 80
Rice enriched 1
2.5
Almond
enriched 50
AS you can see, not all alternative milk products are created equal. If you are purchasing an enriched product (and it should be enriched as un-enriched alternatives contains 40 mg calcium/serving), they are all going to provide comparable calcium and vitamin D. On the other hand, energy, protein and fat content varies considerably. Rice and almond milk are not adequate substitutes with essentially no protein and very little fat. Hemp milk provides a good source of fat but it is also low in protein. Oat milk is an improvement in Protein but not fat. Soy comes the closest but it still has about half the fat and one third the calories of whole milk. Keep in mind that a one year old avoiding whole milk is also avoiding full fat cheese and yogurt and all of the manufactured and processed foods that provide fat such as crackers and cookies and processed meats and likely eating a diet of mostly whole foods, fruits, vegetables, grains and meats. So the fat and protein and energy intake of the solid food diet must be assessed before making a decision about which alternative milk to use. Also, I should mention that goat’s milk or sheep’s milk are not options as the risk of cross reactivity between goat and sheep’s milk is >90% 47

48. Wheat Avoidance
Bread, cereal, pasta, crackers, cookies, cakes, condiments, marinades, cold cuts, soups, low-fat or non-fat products
4 servings of enriched and whole grains provides 50% of the RDA for CHO, iron, thiamin, riboflavin and niacin for children>1 yr. and also a significant source of B6 and manganese.
Wheat avoidance will have significant nutritional impact.
Cho- the main source of energy for the brain
Not to mention fiber and many of the enriched products now contain Folate, which is turning out to be a major dietary source of this nutrient.. It is always important to recommend nutrition rich dietary alternatives – without alternatives to wheat- nutritional inadequacies are likely- corn chips are not a nutritional equivalent to wheat.

49. Alternative Grains Rice Corn Oat Rye Barley Buckwheat Amaranth Quinoa
Millet
Rice and corn tend to be the most often tolerated- oat next
Rye and barley are more likely to cross react. WE don’t have enough information on the “designer grains”
Providing enriched or whole grains will greatly improve the nutritional quality of the diet.

50. Cross-Reactive Grains
20% of those with wheat allergy may be clinically reactive to another grain.
*Use of alternative grains should be individualized and based on tolerance as determined by the patient history or by the allergist.
On the other hand 80% have only wheat allergy-

51. Differences in Management of Wheat Allergy and Celiac Disease
Celiac—Autoimmune disorder caused by gluten sensitivity
Strict, lifelong avoidance of wheat, rye, and barley
All non-gluten grains allowed: Amaranth, arrowroot, buckwheat, corn, legume flours, millet, Montina, nut flours, rice, potato flours or starch, sorghum, tapioca, teff, quinoa
Pure uncontaminated oats—most organizations allow moderate amounts of gluten free oats
Oats are generally tolerated by wheat allergic

52. Egg/Soy/Peanut Generally, does not have as great a nutritional impact
Greater concern if MFA or if other dietary patterns (vegetarian)
Not that these foods are not nutritionally dense, but the generally do not provide a large percentage of daily caloric intakes, so finding dietary substitutes is easier and not as urgent

53. Future Directions Oral Immunotherapy Sublingual Immunotherapy
Food Allergy Herbal Formula (Chinese herbal)
Cooked milk and cooked egg

54. Food Allergy Management
There is no cure—avoidance is the only way to prevent food allergic reactions
Avoidance issues have many nuances and extensive education is required to prevent accidental ingestions
Create policy’s and provide training in your food service establishments
Avoidance diets are not without nutritional risk
Groetch 2011

55. Resources for Food Service, Nurses and Educators
Welcoming Guests with Food Allergy
Food Allergy Training Guide for College Food Service
How to Care for Students with Food Allergies: What Educators Should Know
Online Food Allergy Toolkit for School Nurses
Groetch 2011

56. Resources The Food Allergy and Anaphylaxis Network www.foodallergy.org
Food Allergy Initiative
American Academy of Allergy, Asthma and Immunology
The Jaffe Food Allergy Institute
CoFAR

57. Resources
Understanding and Managing your Child’s Food Allergies by Scott H. Sicherer
Food Allergies for Dummies by Robert Wood
Pediatric Nutrition Care Manual - online
UpToDate has extensive FA information topics
CoFAR Food Allergy Education Program

58. References
Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J Am Diet Assoc. 2002;102:
Isolauri E, Sutas Y, Salo MK, Isosomppi R, Kaila M. Elimination diet in cow's milk allergy: Risk for impaired growth in young children. J Pediatr. 1998;132:
Henriksen C, Eggesbo M, Halvorsen R, Botten G. Nutrient intake among two-year-old children on cows' milk-restricted diets. Acta Paediatr. 2000;89:
Fortunato JE, Scheimann AO. Protein-energy malnutrition and feeding refusal secondary to food allergies. Clin Pediatr (Phila). 2008;47:
Liu T, Howard RM, Mancini AJ, et al. Kwashiorkor in the united states: Fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol. 2001;137:
Fox AT, Du Toit G, Lang A, Lack G. Food allergy as a risk factor for nutritional rickets. Pediatr Allergy Immunol. 2004;15:
American academy of pediatrics. Committee on Nutrition. Hypoallergenic Infant Formulas. Pediatrics. 2000;106:

59. References (continued)
Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol ; 126 (6): S1-58.
"Food allergen labeling consumer protection act of 2004"
Sheth SS, Waserman S, Kagan R, Alizadehfar R, Primeau MN, Elliot S et al. Role of food labels in accidental exposures in food-allergic individuals in Canada. Ann Allergy Asthma Immunol 2010; 104(1):60-5.