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Accommodating and Educating Students with Food Allergy Marion Groetch, MS, RD Director, Nutrition Services Jaffe Food Allergy Institute.

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Presentation on theme: "Accommodating and Educating Students with Food Allergy Marion Groetch, MS, RD Director, Nutrition Services Jaffe Food Allergy Institute."— Presentation transcript:

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. Define the difference between food allergy and food intolerance. Describe the steps involved in the allergy evaluation. Describe the steps involved in the allergy evaluation. Acquire the skills and identify resources to provide comprehensive education for allergen elimination diets. Acquire the skills and identify resources to provide comprehensive education for allergen elimination diets. Understand the nutritional risks of allergen elimination diets. Understand the nutritional risks of allergen elimination diets. Identify resources for Job Corps food service staff, nurses and center personnel. 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. 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. 2010; 126 (6): S1-58

4 Definition of Food Allergy (FA) Food allergy 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

5 Food Allergies Can Be Life-Threatening More people die each year from food allergy-induced reactions than to reactions to insect stings. 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. 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. 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.

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8 Eosinophilic esophagitis Eosinophilic gastritis Eosinophilic gastroenteritis Atopic dermatitis Food Allergy Immunoglobulin E (IgE) -Mediated (most common) Non-Immunoglobulin E Mediated Cell-Mediated Immunologic 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 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 Role of the primary care physician or Board Certified Allergist Detailed medical and dietary history with a focus on symptoms Detailed medical and dietary history with a focus on symptoms Identify general approach Identify general approach Allergy vs. intolerance Allergy vs. intolerance IgE vs. non-IgE IgE vs. non-IgE Thorough physical exam Thorough physical exam Diagnostic tests to rule out other medical conditions not related to food allergy Diagnostic tests to rule out other medical conditions not related to food allergy

10 Food Allergy Testing—IgE Prick Skin Test (PST)—IgE Prick Skin Test (PST)—IgE Serum IgE–(CAP–System FEIA) Quantitative measurement of food specific IgE Serum IgE–(CAP–System FEIA) Quantitative measurement of food specific IgE Double Blind Placebo Controlled Food Challenge- Considered “Gold Standard” for FA diagnosis Double Blind Placebo Controlled Food Challenge- Considered “Gold Standard” for FA diagnosis 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. 2010; 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. 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. 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. 2010; 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. 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. 2010; 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. 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. 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. Removal of the suspected allergen with anticipated significant improvement or remission of symptoms. 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. 2010; 126 (6): S1-58

14 Disorders Not Proven to be Related to Food Allergy Migraines Migraines Behavioral / Developmental disorders Behavioral / Developmental disorders Arthritis Arthritis Seizures Seizures Inflammatory bowel disease Inflammatory bowel disease

15 Unproven Diagnostic Tests Basophil histamine release/activation Basophil histamine release/activation Lymphocyte stimulation Lymphocyte stimulation Facial thermography Facial thermography Gastric juice analysis Gastric juice analysis Endoscopic allergen provocation Endoscopic allergen provocation Hair analysis 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. 2010

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. 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. 2010; 126 (6): S1-58

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

18 Label Reading Read the entire product label each and every time an item is purchased. Read the entire product label each and every time an item is purchased.

19 Label Reading Food Allergen Labeling Consumer Protection Act (FALCPA) Milk Milk Egg Egg Wheat Wheat Soy Soy Peanut Peanut Tree nut* Tree nut* Fish* Fish* Crustacean shellfish* Crustacean shellfish* *Specific species must be listed *Specific species must be listed "Food allergen labeling consumer protection act”

20 Incidental Ingredients A “major food allergen” may not be omitted from the product label even if it is only a minor ingredient. 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. Allergens not considered “major” may remain unidentified on product labels.

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. Cross contact occurs when safe foods come in contact with an allergen, causing the safe food to contain small amounts of unintentional allergenic ingredients.

22 Cross Contact Precautionary labeling such as Precautionary labeling such as May contain… May contain… Manufactured in a facility… Manufactured in a facility… Manufactured on shared equipment… Manufactured on shared equipment… Voluntary and unregulated Voluntary and unregulated

23 The Amount of Allergen in Products Assessed Hefle et al JACI /68 3/57 2/51 Overall 7% of all products (n=179) with advisory statements tested contained detectable allergen residue. % of products with detectable allergen With permission, Scott Sicherer, MD

24 Risk Associated with Milk Advisory Statements Overall milk was detected in 36% of products (n=147) 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. Dark chocolate had the highest % with detectable milk in 82% of samples with milk advisory statements. Crotty JACI 2010

25 Food Allergy Guidelines NIAID guidelines suggest avoiding any product that has any advisory statement for your allergen. 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. Read product labels each and every time an item is purchased. Look at the ingredient list and precautionary labels. Look at the ingredient list and precautionary labels. Avoid products that have a precautionary statement for your allergens. Avoid products that have a precautionary statement for your allergens. May need to call manufacturers for additional product information. 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. 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. Employees should understand how cross-contact can occur.cross-contact 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. 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. 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. 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 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! If a student is having an allergic reaction, call 911 and get medical help immediately! Groetch 2011

29 Cross-Contact in the Cafeteria Utensils, dishes Utensils, dishes Cutting boards Cutting boards Grinders, blenders Grinders, blenders Hands Hands Gloves (no latex) Gloves (no latex) Processors Processors Salad bars Salad bars Pots, pans Pots, pans Fryers Fryers Grills Grills etc., etc... etc., etc... Consider anything used for more than one food and not cleaned completely!

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

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

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

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

35 To Avoid or Not to Avoid A patient with corn allergy? A patient with corn allergy? Corn oil or corn syrup? Corn oil or corn syrup? A patient with soy allergy? A patient with soy allergy? Soy oil or soy lecithin? Soy oil or soy lecithin? A patient with peanut allergy? A patient with peanut allergy? Peanut oil? 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? A patient with sesame allergy? Sesame oil? Sesame oil? A patient with egg allergy? A patient with egg allergy? Egg white or egg yolk? Egg white or egg yolk? A patient with peanut allergy? A patient with peanut allergy? Tree nuts or other Legumes? Tree nuts or other Legumes? 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/ Health and Wellness Center /Cafeteria/ Center personnel Student informs Health and Wellness Center and the Cafeteria of the food allergy 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 ensures the student has an Emergency Treatment plan signed by MD Health and Wellness Center and Cafeteria communicate information about student’s allergy Health and Wellness Center and Cafeteria communicate information about student’s allergy

39 It Takes a Team: Cafeteria Strict Avoidance – one bite can hurt Strict Avoidance – one bite can hurt Know ingredients/Know the student with allergies Know ingredients/Know the student with allergies Read all labels – contact manufacturers Read all labels – contact manufacturers Store ingredients to prevent cross contact Store ingredients to prevent cross contact Use clean utensils, cooking areas and cooking equipment Use clean utensils, cooking areas and cooking equipment May consider a designated area for prep of allergen-free foods. May consider a designated area for prep of allergen-free foods. Prepare allergen free foods first, cover and remove from cooking area Prepare allergen free foods first, cover and remove from cooking area Serve separately – not from cafeteria line Serve separately – not from cafeteria line

40 It Takes a Team Assure correct personnel are identified Assure correct personnel are identified Identify those trained in food prep for the students with allergies 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 trained to answer questions about ingredients and food prep methods Identify those who will enact emergency action in the event of a reaction 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 Identify JC center environments that might pose a risk and create procedures to reduce risk If a reaction occurs, activate emergency action promptly If a reaction occurs, activate emergency action promptly

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

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

43 Nutrition Counseling Food Allergy Guidelines recommends all children with food allergy receive nutrition counseling and close growth monitoring. Food Allergy Guidelines recommends all children with food allergy receive nutrition counseling and close growth monitoring. 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 Macronutrient/Micronutrient deficiencies or imbalance Shorter stature Shorter stature Failure to thrive Failure to thrive Nutritional Rickets/kwashiorkor/marasmus 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. Isolauri E, et al. J Pediatr. 1998;132:1004–1009. Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569. Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569. Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499. Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499. Flammarion et al. Pediatr Allergy Immunol. 2011; 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 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

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 / 100 Soy enriched / 100 Oat enriched / 100 Hemp enriched / 80 Rice enriched / 100 Almondenriched5012.5

48 Wheat Avoidance Bread, cereal, pasta, crackers, cookies, cakes, condiments, marinades, cold cuts, soups, low- fat or non-fat products 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. 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.

49 Alternative Grains Rice Rice Corn Corn Oat Oat Rye Rye Barley Barley Buckwheat Buckwheat Amaranth Amaranth Quinoa Quinoa Millet Millet

50 Cross-Reactive Grains 20% of those with wheat allergy may be clinically reactive to another grain. 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.

51 Differences in Management of Wheat Allergy and Celiac Disease Celiac—Autoimmune disorder caused by gluten sensitivity Celiac—Autoimmune disorder caused by gluten sensitivity Strict, lifelong avoidance of wheat, rye, and barley 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 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 Pure uncontaminated oats—most organizations allow moderate amounts of gluten free oats

52 Egg/Soy/Peanut Generally, does not have as great a nutritional impact Generally, does not have as great a nutritional impact Greater concern if MFA or if other dietary patterns (vegetarian) Greater concern if MFA or if other dietary patterns (vegetarian)

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

54 Food Allergy Management There is no cure—avoidance is the only way to prevent food allergic reactions 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 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 Create policy’s and provide training in your food service establishments Avoidance diets are not without nutritional risk Avoidance diets are not without nutritional risk Groetch 2011

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

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

57 Resources Understanding and Managing your Child’s Food Allergies by Scott H. Sicherer Understanding and Managing your Child’s Food Allergies by Scott H. Sicherer Food Allergies for Dummies by Robert Wood Food Allergies for Dummies by Robert Wood Pediatric Nutrition Care Manual - online Pediatric Nutrition Care Manual - online UpToDate has extensive FA information topics UpToDate has extensive FA information topics CoFAR Food Allergy Education Program 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 Referencescontinued 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. 2010; 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.


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