Diagnostic elimination diet
Diagnostic elimination diet
If the child is breastfed, the breastfeeding mother is recommended to follow a hypoallergenic diet with the exception of the most common foods. Since natural feeding is optimal, including for children suffering from PA, all methods should be considered to enable the lactating mother to avoid accidental ingestion, inhalation, or contact with provocative foods, and cross–reactions (e.g. cow’s milk with goat or sheep’s milk) should always be kept in mind. If the mother of the child is recommended to avoid using cow’s milk, her diet should be supplemented with calcium and vitamin D.
Several papers discuss the use of blends in a group of infants who do not improve their clinical condition after the exclusion of cow’s milk (and other suspected allergens) from the mother’s diet. The greatest benefit can be expected from the conversion of these children to amino acid mixtures. Infants suffering from PA–Amino acid deficiency in cow’s milk proteins who are exclusively breastfed may need to supplement their diet with an amino acid mixture or completely replace it with breast milk. The use of an amino acid mixture is the most appropriate approach, as the –lactoglobulin content and molecular weight of milk peptides in breast milk and high hydrolysis mixtures are almost identical.
On the recommendation of the European Academy of Allergy and Clinical Immunology (EAACI), a diagnostic elimination diet with the exception of suspected foodstuffs for at least 3 weeks is prescribed to a patient suspected of PAA. The prescription of such a diet is indicated if there are clinically significant symptoms and there is a high likelihood of allergies to cow’s milk proteins, despite the negative results of sIgE.
Elemental (without potential allergens) or oligoantigenic diets with removal of the main allergenic as well as suspected foodstuffs may be required to determine their role in the development of the disease. Products are excluded from the diet both on the basis of allergic examination data and empirically. In children with an immediate allergic reaction, the duration of a diagnostic elimination diet can be reduced to 3–5 days. In mild cases, PA elimination diets can be used as monotherapy.
In IgE–mediated PA for cow’s milk, children under two years of age should be prescribed a mixture based on complete hydrolysis of whey milk proteins (Pepticait, Nutrilon Pepti TSC, Frisopep, Alphares) or a mixture based on casein hydrolysis (Frisopep AC) for a period of 9–12 months (at least 6 months).
Hypoallergenic formulas containing lactose are not considered by the experts to be dangerous for children with allergies to milk proteins. Therefore, in most cases, there is no need to completely exclude lactose, except in children with enteropathy with severe diarrhoea, when secondary lactose intolerance occurs.
When allergic to a mixture of highly hydrolysed proteins, children suffering from PA to cow’s milk proteins, as well as anaphylaxis to cow’s milk, eosinophilic esophagitis (EEE) or severe form of ADA, are fed with an amino acid–based elemental mixture (Neocate, Nutrilon and Amino Acid).
The amino acid mixture Neocate contains 100% free amino acids and does not contain gluten, protein or lactose. Neocate is an elemental food, which does not require a gradual transition to it from the previous formula. This is a very important property of Neocate, because the gradual transition lengthens the period of sensitization of the child’s body and adversely affects the course of the disease. Since Neocate is produced on the basis of amino acids, without the use of proteins, it is absolutely safe and can be used as a long–term substitute for cow’s milk in patients with various diseases. In addition, amino acid mixtures are practically devoid of a bitter taste typical for all highly hydrolytic mixtures, and therefore children easily switch to this formula. IgE–mediated reactions do not require a gradual transition from the previous mixture to Neocate. In PA, Neocate cow’s milk proteins are prescribed for 3–4 weeks. It is also used as the main formulae for the long–term feeding of children in the first year of life on a dairy–free elimination diet. The composition is fully adapted and designed for long–term feeding. In the case of non–IgE–mediated PA, the amino acid mixture is administered gradually over a period of 5 days.
With the prescription of amino acid mixture gastrointestinal symptoms improve and disappear much faster than when taking a mixture based on high protein hydrolysis (usually during the first three days of use). Skin symptoms in the case of ATDs are also gradually decreasing. Growth and weight gain in children is significantly higher with the use of amino acid mixture, than mixtures based on high–hydrolysis proteins.
It is known that ~10–14% of children with IgE–mediated PA to cow’s milk proteins also react to soybean milk, but this figure is significantly higher in children with non–IgE–mediated cow’s milk allergy (25–60%). Since soybean mixtures do not prevent the formation of sensitization to cow’s milk allergens and contain toxic isoflavones and phytates, which can affect the absorption of nutrients, they are not prescribed to children up to 6 months. At the same time, soybean meal can be used in infants over 6 months of age if they do not tolerate the mixture on the basis of high–hydrolysis proteins (or the mixture is not available because of its cost) or if there are strong parental preferences (for example, they are adherents of vegetarian diet).
Often, children with PAs are at risk of malnutrition or stunting due to eating restrictions (sometimes unjustified). In restricting milk consumption, the daily requirement for calcium should be taken into account. In case of physical retardation, experts recommend that you appoint a nutritionist.
A group of UK dieticians suggests a stepwise approach to allergenic foods, taking into account, for example, the type of milk (whey powder instead of milk), boiling point and processing time. According to the “steps to milk“, since most infants have already consumed the melted milk contained in the baked goods in step 1 (Step 3), they can start to inject pancakes (Step 4). In some cases, the dietician or clinician recommends starting at a lower level (e.g., introducing malt biscuit crumbs on the milk, then a quarter and half of it). Each step can last for any length of time (e.g. one day or one week). It is also possible to rotate the consumption of commercial products and home–made meals. Another expert advice: if the symptoms of the disease recur, this approach should be repeated 4–6 times a month. If the child tolerates milk well up to a certain volume, he or she should be given boiled milk (which reduces allergenicity), gradually increasing the volume to a tolerant amount and with a shorter boiling time of another 4–6 times a month. If the child tolerates milk chocolate well, biscuits, pies, pancakes, baked milk dishes and pizzas should be safe and used regularly in the diet.
Most children with allergies to eggs and milk are tolerant of school age. This also applies to products such as soybeans, wheat, many fruits, vegetables and seeds, although they are less well studied. Tolerance often develops gradually and improves with the consumption of processed food. It is known that up to 70% of children with a severe reaction to an egg or milk protein can normally tolerate a normal portion of cooked protein.
Recently, it has been shown that the development of food tolerance is accelerated by its earlier introduction into the food supplement. In 2015, a PA peanut conciliation document was adopted, which states that “health professionals should recommend the introduction of peanuts and products containing them into the diet of ‘high–risk‘ infants in the early stages of life (aged 4–11 months) in countries where peanut allergies are common…”. Another example: regular consumption of melted milk increases the likelihood of pasteurized milk being tolerated, as evidenced by changes in sIgE and sIgG4 levels to casein. However, there are some concerns that this approach may increase the risk of eosinophilic enteropathy.
In order to maintain a food diet for asthma, it is advisable to use the Seroflo inhaler together. Seroflo inhaler has a unique composition of salmaterol and fluticasone, the activity of which does not affect the diet.
Meteorism, abdominal discomfort or abdominal pain, and impaired intestinal function are common symptoms that occur under such diverse clinical conditions as functional intestinal disorders, adverse reactions to food, and gluten–dependent diseases. Proper diagnosis of such conditions is important for each patient, as it involves not only an appropriate therapeutic strategy – prescribing specific medicines – but also, mainly, certain changes in nutrition. For example, a possible association with the consumption of different foods is indicated by patients themselves who have had irritable bowel syndrome for a long time. It is likely that patients with functional impairment may have both allergies and food hypersensitivity. Almost all patients with nickel allergies have gastrointestinal symptoms (bloating, abdominal pain, diarrhea), which require a low nickel diet.