Carrie Ek, RD, LDN, MBA Nutritionist/Registered Dietitian

1. Carrie Ek, RD, LDN, MBANutritionist/Registered Dietitian Dairy Allergy vs. Lactose Intolerance and other Food Allergy vs Sensitivity Dilemmas at School

3. Allergy vs. Intolerance Can someone with an allergy eat small amounts of the food they are allergic to?? True OR False?

4. Allergy Immune response: elevated IgE Can be life threatening (anaphylaxis) even if past reactions have been mild. Itchy throat to full cardiovascular collapse Typically occurs within 2 hours May effect multiple organ systems and can worsen over time An allergic reaction can cause death

5. Pathogenesis: Allergens • Adults - Nuts, peanuts, fish, shellfish, eggs • Children - Eggs, peanuts, milk, soy, fish, wheat • Societal eating patterns influence development of specific food hypersensitivities • Boiled peanuts in Asian cultures, • Lack of Peanut Consumption in Sweden

6. Prevalence of Food Allergy • Perception by public: 20-25% • Confirmed allergy (oral challenge) • Adults: 2-3.5% • Infants/young children: 6-8% • Specific Allergens • Dependent upon societal eating and cooking patterns • Prevalence higher in those with: • Atopic dermatitis • Certain pollen allergies • Latex allergy • Prevalence seems to be increasing

8. Children with food allergies might communicate their symptoms in the following ways: It feels like something is poking my tongue. My tongue (or mouth) is tingling (or burning). My tongue (or mouth) itches. My tongue feels like there is hair on it. My mouth feels funny. There’s a frog in my throat; there’s something stuck in my throat. My tongue feels full (or heavy). My lips feel tight. It feels like there are bugs in there (to describe itchy ears). It (my throat) feels thick. It feels like a bump is on the back of my tongue (throat). Source: The Food Allergy & Anaphylaxis Network

10. Food Intolerance or Sensitivity A food intolerance, or a food sensitivity occurs when a person has difficulty digesting a particular food. A food intolerance is sometimes confused with or mislabeled as a food allergy. Food intolerances involve the digestive system. Gas Abdominal pain diarrhea

11. Causes of Food Intolerance Include: Absence of an enzyme needed to fully digest a food. Lactose intolerance: missing lactase enzyme Irritable bowel syndrome Chronic condition can cause cramping, constipation and diarrhea. Sensitivity to food additives Sulfites to preserve dried fruit, canned goods or wine can trigger asthma in sensitive people. Recurring stress or psychological factors Thought of a food may make you sick. Celiac disease. Autoimmune disease with gastrointestinal symptoms. Not at risk of anaphylaxis.

12. Lactose Intolerance • Deficiency of the lactase enzyme in the intestines • Lactase breaks down lactose (carbohydrate in milk) • Lactose galactose + glucose • 30 minutes-2 hours after ingestion • Symptoms: diarrhea, nausea, cramping, bloating, gas • Highly variable, dose dependent • Often can tolerate some dairy foods

13. Three types of Lactose Intolerance • Primary: lactase enzyme production reduces as a child grows with less as an adult. Genetic component: African, Asian, Hispanic • Secondary: usually temporary due to illness • Congenital: rare, no lactase enzyme production

14. Treatment of Lactose Intolerance Avoid lactose OR add lactase enzyme

16. Legally must be on label in common terms

17. Management of Food Allergy • Complete avoidance of specific food trigger • Ensure nutritional needs are being met • Education • Anaphylaxis Emergency Action Plan if applicable • most accidental exposures occur away from home This frozen dessert could have peanut, tree nut, cow’s milk, egg, wheat

18. Managing Allergies at School - Prevention Safety = Complete Avoidance STRICT no food sharing policy. The child should wear a medic alert bracelet and the office should be provided with complete information about the allergies, e.g., foods to avoid, treatment, and emergency contact numbers. Post the child’s photo with allergy list: In that child’s classrooms, the gymnasium and teachers lounge. Lunch and snack time • In the classroom • Clean desk/table policy, placemats, hand-washing & no food sharing • Letter to class parents regarding the child’s allergies - Ask for their cooperation in reinforcing class food rules with their children.  • Outside the classroom (playground, field trips, buses, arenas etc…) • All volunteers and teachers need to be aware of the child’s allergies • Accommodations must be made when a child cannot attend a trip to an unsafe location (ie. farm or baseball stadium etc…)

19. Managing Allergies in School - Reaction • EpiPen policy • It is not sufficient to have an EpiPen in a cabinet or drawer in the classroom. It must be on the child whenever he/she leaves the classroom (recess, gym, bathroom, field trips etc…) – designated hanging spot for an EpiPouch to be taken when leaving the classroom. • Illinois EpiPen guidelines- • EpiPens should be carried at all times by a person with severe allergies, because it is not enough to have one nearby. • In the event of a reaction: • Administer EpiPen immediately - even mild allergy symptoms can rapidly progress to a life-threatening situation • Call 911 • Everyone who has been treated with epinephrine must be taken to hospital immediately for evaluation because the symptoms may recur and further injections may be required. One epinephrine shot is good for 10 – 20 minutes.

20. Areas of High Risk • Class materials containing allergens • Cross contamination on surfaces • Class parties and celebrations • Field trips • After school programs providing snacks • Food shared on the school bus • Sack lunches • Accidental ingestion in the cafeteria • Cross contamination of prepared food

21. What Works for Cleaning? • Detergent & friction are adequate for removal • Surfaces • Hands • *Sanitizer does NOT remove allergens*

22. Precautionary Allergen Labeling • “May contain…” • “May contain traces of…” • “Manufactured in a facility that processes…” • “Made on shared equipment with…”

25. This is available for download. Parents can add their child’s photo on the plan and review it with caregivers/schools. Available at: www.aaaai.org The form was adapted from J Allergy Clin Immunol 1998;102:173-176 and J Allergy Clin Immunol 2006;117:367-377.

26. What Schools Can Do Create ‘‘allergy-safe” environment Not ‘‘allergen-free” environment • Develop school policies and protocol for management of anaphylaxis • Emergency and Individual Health Care Plan • Training of staff on condition, medications, and emergency plan • Develop strategies to minimize risk of exposure

27. Celiac Disease • 3 million people (1:33 people) • At least 1% of the population in U.S. • 1:22 first degree relative • 1:39, second degree relative • Inherited autoimmune disease • 6-10 years to diagnosis • Can occur with NO symptoms • Untreated can trigger other autoimmune diseases

28. Celiac related diseases Type 1 diabetes Multiple Sclerosis Thyroid disease Arthritis Osteoporosis Infertility Intestinal cancer Dermatitis Herpetiformis Down syndrome Anxiety Depression Sjögren’s syndrome

29. Symptoms of Celiac Disease • Poor growth/short stature/weight loss • Diarrhea • Constipation • Stomach upset • Anemia • Fatigue/irritability • Some people have no symptoms at all. “silent celiac disease."

30. Poor growth Dermatitis Herpetiformis

32. Diagnosis 1) Human Tissue Transglutaminase IgA (tTG) 2) Total Serum IgA (needs to be >20 for tTG to be valid) IgA deficiency→ EMA Must be eating gluten for the testing to be accurate • If positive still need a small bowel biopsy • HLA-DQ2 and HLA-DQ8 genetic tests

34. Treatment for Celiac= Gluten Free Diet • complex diet • Lots of misunderstanding and untrue information • Diet is for life • No cheating

35. Gluten-Free Diet • Gluten= Wheat, Rye and Barley • Gluten= gliadins • 2006 Food Allergen Labeling (FALCPA): only includes major allergens=wheat. • NOT included on label: barley/rye

37. Gluten Containing Foods Bread, cereals, breaded foods Pasta Soy sauce (wheat fermented) Pretzels, crackers, cookies, cakes Pizza, beer, malted liquors Seasoning blends, soups, marinades, veggie burgers, sushi, communion wafers Medicines/vitamins??

39. Gluten-Free Foods Fruits Vegetables Plain meats Most dairy foods Potatoes Rice Corn Quinoa Eggs Most chocolate Popcorn Corn/tortilla chips Plain potato chips

40. Cross Contamination • All foods cooked separately • Do not use same spoon to stir • Separate toaster, colander • Separate PB, jelly, butter • Always use a clean plate • Dips, serving utensils?

41. Treatment and Monitoring • Blood levels: tTG at set intervals • Levels decreasing over time • Follow-up nutrition counseling • Growth and weight should normalize • Multivitamin with minerals for age • Future=maybe vaccine/medicines

44. Additional Resources American College of Allergy, Asthma, and Immunology www.allergy.mcg.edu Asthma & Allergy Foundation of America www.aafa.org/home Food Allergy Initiative www.foodallergyinitiative.org International Food Information Council Foundation www.ific.org School Nutrition Association www.schoolnutrition.org