How to optimize nutrition

management for allergic pediatric

patients? Nutrition point of view
I Gusti Lanang Sidiartha
Konsultan Nutrisi Pediatri & Penyakit Metabolik
FK UNUD – RSUP Sanglah, Denpasar, BALI
No conflict of interest
Topics

´ Food allergy
´ Impact on growth
´ Nutrition management
´ Case study
 Food allergy
a pathological reaction
of the immune system
triggered by the food
protein
• Part of macronutrients
• Directly influence linear growth
Most children develop food
allergy within the first 2
years of life, which is a
crucial period of growth
Affected and development.
children
Food
allergy

• 95% causes of food allergy:

• Cow’s milk Treatment
• Egg Principle of treatment is
• Peanut
• Tree nut
avoiding food or foods
• Fish that cause symptoms
• Soy
• wheat

GROWTH ?
• Failure to thrive, stunting !
• Cognitive impairment
Mehta et al., 2013 • Non-communicable diseases
DOHaD
hypothesis

Developmental
origins of health
and disease

Malnutrition in
early life (first
1000 days of
life)
Protein deficiency
è slowing/stop
linear growth
(Golden, 1995)
 Double impact of food allergy on the
growth of children
How to optimize nutrition
management for allergic
pediatric patients?
Nutrition point of view

Children
Allergic food with poor Food
reaction growth avoidance

Goal of nutrition management: Appropriate

• Prevent allergic reactions food substitution
• Ensure adequate growth
• Recognize and treat malnutrition
Underlying mechanism of the poor
growth in pediatric food allergy
´ Decreasing of calorie intake
´Loss of appetite
´Early satiety of foods
´ Inadequate of calorie absorption
´ Increasing of metabolic needs

Giovannini et al. 2014

Cytokine pathways in allergic disease

Allergic reactions also

promote pro-inflammatory
cell recruitment and cause
chronic tissue inflammation

William et al., Toxicologic Pathology, 2012;40:201-215

Pathophysiology of inflammatory
anorexia in chronic disease
´ Pro-inflammatory cytokines
stimulate the activity of
anorectic POMC neurons and
inhibit the activity of
orexigenic AgRP/NPY neurons.
´ This leads to increased
signaling at the MC4R, which
results in decreased food
intake and increased energy
expenditure.

Braun & Marks. J Cachexia Sarcopenia Muscle, 2010;1:135-145

Risk factors of the poor growth in
pediatric food allergy
´ Delayed diagnosis
´ Onset of disease in early age
´ Multiple food allergies
´ Disease in active phase
´ Persistent intestinal
inflammation
´ Elimination of most foods from
the diet
´ Elimination from the diet of
foods with high nutritional
value (milk, egg)
´ Poor compliance to dietary
management
´ Extreme self-limitation of food
´ Association with atopic
diseases (asthma, atopic
eczema) or with chronic
diseases
Giovannini et al., 2014
May failure to thrive in infants be a clinical
marker for early diagnosis of food allergy ?

Terminology of failure to thrive:

´ Weight-for-age fall below the 3rd percentile
´ Weight-for-length fall below the 5th percentile
´ Weight deceleration crosses two major percentile lines

Diaferio et al., Nutrients, 2020;12:466

Diaferio et al., Nutrients, 2020;12:466
´ In breastfeed infants: cow’s milk-free diet in their mothers.
´ In non-breastfeed infants: the use of eHF or amino-acid based formula may be helpful in
resolving the growth problem.
´ FTT may be indeed a useful clinical marker for early identification of CMA, particularly in
non-IgE mediated forms.

Diaferio et al., Nutrients, 2020;12:466

 Mediated reactions, affected organ/system
and symptom domination

SKIN

IgE Non IgE

AIRWAY
mediated mediated SKIN

INTESTINAL
AIRWAY

Mixed
INTESTINAL
• Oral allergy syndrome
• Eosinophilic esophagitis
Yu et al., 2016 • Food protein induced enteropathy
Case illustration 1
female, 1.5 y, BW 6.5 kg initially and increased to be 10 kg in 3 months
after amino acid formula treatment
 Micronutrient status of children
consuming a cow’s milk exclusion diet

The risk of B12 deficiency was high in mBF infants on CME diet, and CF was associated with better B12
status. Iron, zinc, and vitamin D deficiencies were present in all feeding groups. Appro-priate CF should
be introduced at 4 to 6 months of age. Vitamin D supplement is recommended to ensure adequate
intake.

Kvammen et al., JPGN, 2018;66:831-837.

Identifying Nutrients at Risk with
Exclusion Diets
Nutrition management
according to pediatric nutrition care
´ Nutrition assessment:
´Diet history
´Anthropometric measurement
´Laboratory bio marker
´ Nutrition requirement ~ RDA
´ Nutrition routes
´Oral – enteral – parenteral nutrition
´ Food selection
´ Follow-up
Nutrition assessment

´ Diet history ´ Feeding pattern

´ Breastfeeding ´ Regular
´ Formula feeding ´ Distraction
´ Complementary feeding
´ Food avoidance
´ Food supplementation
 Anthropometric measurements
Simplified field tables

Length-for-age BOYS
Birth to 2 years (z-scores)
H/A < -2SD è stunting
è Chronic malnutrition
Year: Month Months -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD

0: 0 0 44.2 46.1 48.0 49.9 51.8 53.7 55.6

0: 1 1 48.9 50.8 52.8 54.7 56.7 58.6 60.6

0: 2 2 52.4 54.4 56.4 58.4 60.4 62.4 64.4

0: 3 3 55.3 57.3 59.4 61.4 63.5 65.5 67.6

0: 4 4 57.6 59.7 61.8 63.9 66.0 68.0 70.1

0: 5 5 59.6 61.7 63.8 65.9 68.0 70.1 72.2

0: 6 6 61.2 63.3 65.5 67.6 69.8 71.9 74.0

0: 7 7 62.7 64.8 67.0 69.2 71.3 73.5 75.7

0: 8 8 64.0 66.2 68.4 70.6 72.8 75.0 77.2

0: 9 9 65.2 67.5 69.7 72.0 74.2 76.5 78.7

0:10 10 66.4 68.7 71.0 73.3 75.6 77.9 80.1

0:11 11 67.6 69.9 72.2 74.5 76.9 79.2 81.5

1: 0 12 68.6 71.0 73.4 75.7 78.1 80.5 82.9

1: 1 13 69.6 72.1 74.5 76.9 79.3 81.8 84.2

1: 2 14 70.6 73.1 75.6 78.0 80.5 83.0 85.5

1: 3 15 71.6 74.1 76.6 79.1 81.7 84.2 86.7

1: 4 16 72.5 75.0 77.6 80.2 82.8 85.4 88.0

1: 5 17 73.3 76.0 78.6 81.2 83.9 86.5 89.2

1: 6 18 74.2 76.9 79.6 82.3 85.0 87.7 90.4

1: 7 19 75.0 77.7 80.5 83.2 86.0 88.8 91.5

1: 8 20 75.8 78.6 81.4 84.2 87.0 89.8 92.6

1: 9 21 76.5 79.4 82.3 85.1 88.0 90.9 93.8

1:10 22 77.2 80.2 83.1 86.0 89.0 91.9 94.9

1:11 23 78.0 81.0 83.9 86.9 89.9 92.9 95.9

2: 0 24 78.7 81.7 84.8 87.8 90.9 93.9 97.0

WHO Child Growth Standards
Weight-for-height
Simplified field tables

Weight-for-length BOYS
Birth to 2 years (z-scores)

´ W/H < -2SD

cm -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD

45.0 1.9 2.0 2.2 2.4 2.7 3.0 3.3

45.5 1.9 2.1 2.3 2.5 2.8 3.1 3.4

46.0 2.0 2.2 2.4 2.6 2.9 3.1 3.5

46.5

47.0

47.5
2.1

2.1

2.2
2.3

2.3

2.4
2.5

2.5

2.6
2.7

2.8

2.9
3.0

3.0

3.1
3.2

3.3

3.4
3.6

3.7

3.8
´ Acute malnutrition
48.0 2.3 2.5 2.7 2.9 3.2 3.6 3.9

48.5 2.3 2.6 2.8 3.0 3.3 3.7 4.0

49.0 2.4 2.6 2.9 3.1 3.4 3.8 4.2

49.5 2.5 2.7 3.0 3.2 3.5 3.9 4.3

50.0 2.6 2.8 3.0 3.3 3.6 4.0 4.4

50.5 2.7 2.9 3.1 3.4 3.8 4.1 4.5

51.0 2.7 3.0 3.2 3.5 3.9 4.2 4.7

51.5 2.8 3.1 3.3 3.6 4.0 4.4 4.8

52.0 2.9 3.2 3.5 3.8 4.1 4.5 5.0

52.5 3.0 3.3 3.6 3.9 4.2 4.6 5.1

53.0 3.1 3.4 3.7 4.0 4.4 4.8 5.3

53.5 3.2 3.5 3.8 4.1 4.5 4.9 5.4

54.0 3.3 3.6 3.9 4.3 4.7 5.1 5.6

54.5 3.4 3.7 4.0 4.4 4.8 5.3 5.8

55.0 3.6 3.8 4.2 4.5 5.0 5.4 6.0

55.5 3.7 4.0 4.3 4.7 5.1 5.6 6.1

56.0 3.8 4.1 4.4 4.8 5.3 5.8 6.3

56.5 3.9 4.2 4.6 5.0 5.4 5.9 6.5

57.0 4.0 4.3 4.7 5.1 5.6 6.1 6.7

57.5 4.1 4.5 4.9 5.3 5.7 6.3 6.9

58.0 4.3 4.6 5.0 5.4 5.9 6.4 7.1

58.5 4.4 4.7 5.1 5.6 6.1 6.6 7.2

59.0 4.5 4.8 5.3 5.7 6.2 6.8 7.4

59.5 4.6 5.0 5.4 5.9 6.4 7.0 7.6

Weight faltering/failure to thrive

• Weight/age less than 5th centile

• Weight/height less than 5th centile
• Weight crossing two major percentile lines
• Weight increment less than 5th centile
Laboratory bio-markers

´ Complete blood count

´ Electrolytes
´ Creatinine
´ Lipid profile (total cholesterol, HDL, LDL, triglycerides)
´ Protein profile (albumin, prealbumin, RBP)
´ Iron status (serum iron, ferritin, transferrin)
´ Urine analysis
´ Stool analysis with occult blood
Main plasma proteins used as markers
of nutritional status
Plasma protein Distribution volume and Plasma levels
half-life range
Albumin Distribution volume: large 3.6-4.5 g/dl
Half-life range: 15-20 days
Pre-albumin Distribution volume: small 17.6-36 mg/dl
Half-life range: 2-3 days
Retinol-binding Distribution volume: small 60 + 16 mg/l
protein (RBP) Half-life range: 12 hours

Giovannini et al. Italian Journal of Pediatrics 2014, 40:1

Nutrition requirement
RDAs for Energy and Protein
Category Age (y) Energy Protein (g/kg/d)
(kcal/kg/d)
Infants 0.0 – 0.5 108 2.2
0.5 – 1.0 98 1.5
Children 1–3 102 1.2
4–6 90 1.2
7 – 10 70 1.0
Male 11 – 14 55 1.0
15 – 18 45 0.8
Female 11 - 14 47 1.0
15 – 18 40 0.8
Nutrition requirement

Giovannini et al. Italian Journal of Pediatrics 2014, 40:1

Food protein sources

´ Biological value/complete amino acids:

´ animal protein > plant protein
´ Bioavailability of plant protein 10-20% lower than animal
protein
´ Protein hydrolysates or amino acid-based formula may
be necessary for children older than 1 year to ensure an
adequate protein intake.
´ Energy and protein demands of children with food
allergy could be greater than the recommended values
Composition of human milk and other
formula in 100 ml
Nutrient Human Infant eHF AA formula Soy formula
milk formula
Energy (kcal) 70 67 67 67 67
Protein (g) 1.3 1.5 1.8 1.8 1.7
Fat (g) 4.2 3.6 3.5 3.4 3.5
CHO (g) 7.0 7.2 6.8 7.2 7.0
Calcium (mg) 35 46 50 65 70
Sodium (mg) 15 16 18 26 24
Zinc (mg) 0.3 0.6 0.5 0.7 0.8
Iron (mg) 0.1 0.8 0.7 1.0 1.2
Retinol (ug) 60 75 52 56 60
Vit. D (ug) 4 9 1.3 1.2 1.0
Nutrients composition of egg, chicken,
beef, fork, and peanut in 100 g
Nutrient egg chicken beef fish peanut
Energy (kcal) 155 239 250 205 567
Protein (g) 13 27 26 22 26
Fat (g) 11 14 15 12 49
CHO (g) 1.1 0 0 0 16
Calcium (mg) 50 15 18 15 92
Magnesium (mg) 10 23 21 30 168
Iron (mg) 1.2 1.3 2.6 0.3 4.6
Vit. B12 (ug) 1.1 0.3 2.6 2.8 0
Retinol (IU) 520 161 0 50 0
Vit. D (IU) 87 2 7 0 0
The limiting essential amino acid in
cereals and legumes
Food Methionine Lysine Tryptophan
Legumes D
Nuts D
Cereals D
Maize D D
Walnuts D D
Hazelnuts D D
Rice with Almond D

D = deficient (limiting) amino acid

Essential amino acids composition of
foods (mg/g protein)
EAA Milk Egg Beef Wheat Rice Soy
Phenylalanine + Tyrosine 102 93 80 80 91 88
Histidine 27 22 34 25 26 28
Isoleucine 47 54 48 35 40 50
Leucine 95 86 81 72 86 85
Lysine 78 70 89 31 40 70
Methionine 33 57 40 43 36 28
Threonine 44 47 46 31 41 42
Valine 64 66 50 47 58 53
Tryptophan 14 17 11 12 13 14
All EAA 477 490 445 351 405 430
Follow-up

´ Follow-up of allergic children on exclusion diet is

essential
´ Children’s diet vary as they get older, and nutritional
requirements also change accordingly.
´ Monitor dietary compliance
´ Monitor weight and length or height ~ target
Case illustration 2
male, birth 27-06-2018, BW 4.2 kg BL 52 cm. At 3.5 months weight
5.2 kg, length 64 cm (first admitted at Sanglah)

´ Clinical: recurrent diarrhea since neonate

´ Diet history: breast milk, cow’s milk formula, soy formula,
extensive hydrolyzed formula
´ Recurrent hospitalized
´ Laboratory:
´ Hypoglycemia
´ Metabolic acidosis, increased anion gap
´ Total IgE : 53.3 (reference < 29)
´ Stools: FOBT (+)
Case illustration 2
male, age 3.5 months, W 5.2 kg, L 64 cm

´ Anthropometric measurement
´ Weight: 5.2 kg (W/A: < -1SD)
´ Length: 64 cm (L/A: > median)
´ W/L: < -3 SD
´ Nutrition requirement
´ RDA = 7 x 108 kcal = 756 kcal/d
´ Nutrition route: oral
´ Food selection
´ Amino acid formula = 8 x 95 kcal (140 ml)
´ Follow-up: acceptability and tolerance
Follow-up

´ Failure to thrive
´ Treatment with amino
acid formula 8 x 140 ml
´ Symptom (recurrent
vomit and diarrhea)
improvement
´ Next month Weight 6.8
kg (increased 1.6 kg)
Follow-up: now 26 months, weight
14.8 kg
Summary

´ Children with food allergy are at risk to be poor growth

´ Exclusion diet may cause nutritional and growth deficiency
´ A multidisciplinary approach is needed, includes pediatric allergology's,
pediatric nutritionist, dietician, nurses, psychologist.
´ The goals are treat the food allergic disease and ensure optimal growth
and development
Thank You