Label Reading

Those shopping for a family member with food allergies must understand how to read and interpret product labels to successfully identify and eliminate food allergens.

Food labeling legislation is dependent on the country or region in which the product is sold. Ingredients considered major allergens based on the labeling laws of a specific country or region are listed in Table 48-1 .

In the United States of America (USA), The Food Allergen Labeling and Consumer Protection Act (FALCPA) mandates clear, plain language labeling of all ingredients derived from the foods considered major allergens. Those foods considered major allergens in the USA are listed in Table 48-1 . The plain language stipulation requires the presence of a major food allergen to be listed, using its common name (e.g. milk) rather than a scientific term (e.g. casein, whey) on the product label in one of the following ways:

• •
  

  In parentheses, following the food protein derivative, for example: casein (milk)

  
  
• •
  

  In the ingredient list, for example: milk, wheat, peanut

  
  
• •
  

  Immediately below the ingredient list in a ‘contains’ statement, for example: CONTAINS EGG.

Additionally, a major food allergen may not be omitted from the product label even if it is only an incidental ingredient such as in a spice, flavoring, coloring, additive, or used merely as a processing aid. These regulations only apply to ingredients derived from the eight foods that are considered the major allergens. An individual with allergy to an ingredient not covered under FALCPA, such as garlic or sesame, would still need to call the manufacturer to ascertain if garlic, sesame or sesame oil was included in a vague ingredient term such as ‘spice’ or ‘natural flavoring’ of a product.

Manufactured food products, including those imported for sale in the USA, dietary supplements, medical foods and infant formulas are all required to comply with FALCPA. Currently, highly refined vegetable oils derived from major food allergens (including highly refined soy and peanut oils) are not considered allergens by FALCPA because highly refined oils have almost complete removal of allergenic protein and have not been shown to pose a risk to human health. In the USA, soy oil is almost always a highly refined oil, meaning it would not be considered an allergenic ingredient. Peanut oil, on the other hand, may or may not be highly refined. Peanut oil can also be present as expeller-pressed, cold-pressed, expelled or extruded, which may contain enough peanut protein to cause an allergic reaction. As the ingredient list of a finished food will not tell a consumer the nature of the oil ingredient or how the oil was processed, it will not be possible to tell from a product label if the peanut oil listed is highly refined or otherwise processed. Calling the manufacturer may provide more specific information. However, since peanut oil is infrequently used in manufactured products and the labeling of the oil is not sufficient to determine if the ingredient is safe, avoidance of peanut oil is frequently recommended. Tree nut oils and sesame oil are typically not highly refined and will pose a risk to allergic consumers and therefore should be avoided.

The presence of ingredients in manufactured foods due to cross-contact is not required to be listed on product labels. Cross-contact occurs when an ‘allergen-safe’ food unintentionally comes in contact with an allergen during the use of shared storage, transportation or production equipment or routine methods of growing and harvesting crops. Cross-contact may lead to significant levels of hidden allergens in a product without identification on the product label. Many manufacturers are addressing the issue of cross-contact with precautionary labeling such as: ‘May contain [allergen]’, ‘Manufactured in a facility that also manufactures [allergen]’ or ‘Manufactured on shared equipment with [allergen]’. Those with food allergies should be aware that these statements are currently voluntary and unregulated. A variety of statements are being employed, some of which provide food allergic consumers with little meaningful information on the potential presence of allergens in pre-packaged foods. For instance, in a 2010 study, product labels stating, ‘Good Manufacturing Practices were used to segregate ingredients in a facility that also processes peanut, tree nuts, milk, shellfish, fish, and soy ingredients,’ were interpreted to mean that the product was safe for these otherwise undisclosed ingredients; however, milk was detected in two, and egg in one of the three products with this statement. A 2007 study by Hefle and colleagues evaluated 179 products with peanut advisory labeling. Two different lot numbers of each of these 179 products were analyzed for detectable peanut allergen. The results revealed that 7% (13/179) of the products tested contained detectable levels of peanut in one or both lots and the type of advisory statement used did not reflect the degree of risk. Precautionary statements carry a small but real risk to the consumer with food allergies and no one statement represents a greater or lesser degree of risk than another. The FDA is currently working on developing a long-term strategy to assist manufacturers in using allergen precautionary labeling that is truthful and not misleading, conveys a clear and uniform message and adequately informs US consumers of risk. In the USA, the National Institutes of Allergy and Infectious Diseases (NIAID) expert panel guidelines for the diagnosis and management of food allergy suggest advising patients to avoid precautionary-labeled products. However, individual guidance based on clinical assessment may be appropriate.

Although similar legislation exists in many countries, the foods identified as allergens (see Table 48-1 ) and slight variations of regulations exist. For instance, precautionary statements in Canada must use the wording, ‘May Contain –,’ to prevent confusion and misinterpretation. Unique to the European Union (EU) food businesses are required to provide allergy information on food sold unpackaged or pre-packed for direct sale (such as in bakeries, delicatessens and caterers). In Australia, a voluntary incident trace allergen labeling (VITAL) system may be used by food producers to provide standardized, consistent precautionary advice to consumers with food allergy.

Although label ambiguities continue to exist, the package label provides information to the consumer about the contents of a product and should be read each and every time a product is purchased. Healthcare professionals must be prepared to offer extensive education to patients with food allergies so that safe food selections can be made.

Daily Living with Food Allergies

Once a food item is purchased and brought into the home, that item must continue to be carefully handled to prevent cross-contact with the identified allergen. Storage of ingredients in the home should be planned to prevent cross-contact. A separate shelf in the refrigerator or cupboard may be reserved for the allergen-free foods. Meal preparation to prevent cross-contact in the home is also essential. All food preparation areas, cooking utensils and cooking equipment should be cleansed with warm soapy water and rinsed. Allergen-free foods and meal items can be prepared first, covered, and removed from the area prior to the preparation of other foods for the home. Families will also benefit from guidance on how to prepare meals without their allergenic ingredients.

Families living with food allergies report that avoiding eating in restaurants is the number one cause of decreased quality of life due to the food allergy. Those with food allergies may be especially at risk while dining out since restaurants are not required to list ingredients and the wait staff is generally ignorant about the ingredients in a dish.

Planning ahead and communication with restaurant staff is the first key step in obtaining a safe restaurant meal. Calling ahead to ask how a food allergy is accommodated as well as avoiding the restaurant’s busiest hours is often helpful. Families should be taught to inform the staff that their child has a food allergy, not simply to ask if a menu item contains their allergen. ‘Chef Cards’ provide a written list of ingredients to avoid for specific allergens and are available from organizations such as Food Allergy Research and Education (FARE; www.foodallergy.org ). In addition to ingredient inquiries, families must learn to inform restaurant staff about cross-contact risk. Cross-contact in a restaurant environment is not uncommon. For example, the same grill might be used to make a cheeseburger that is used for a plain hamburger, or the French fries might have been cooked in the same deep fat fryer as fried shrimp or milk-containing onion rings. The same tongs or mixing bowls may be used to assemble a salad with nuts as are used to assemble a plain green salad. Families should be taught to speak directly to the chef or food service manager to inquire about ingredients and cross-contact risk. It is important to inform the chef that a clean cooking area, cooking equipment and utensils must be used. Ordering single ingredient foods, prepared simply, will decrease the risk of hidden ingredients. When the food arrives at the table, families should confirm with the chef that the meal was prepared correctly and not have their child eat the food if there is any doubt as to the safety of the meal. Lastly, as always, emergency medications should be available when eating at home or away from home.

Certain types of eating establishments will present a greater risk of allergen exposure. For example, cafeterias, buffets and salad bars have inherently greater risk of cross-contact due to spillage and shared serving utensils. Asian and other ethnic restaurants may use more allergenic ingredients (soy, peanuts, tree nuts, fish and shellfish) in a wide variety of dishes and the cooking equipment is generally not washed between each meal prepared. Ice cream parlors use the same scooper for all flavors of ice cream. Asking for a clean scooper may not eliminate the risk as previous servings with a contaminated scooper into the otherwise safe flavor may have already caused cross-contact. For seafood allergies, seafood restaurants may be problematic even if a non-seafood item is ordered because of the greater risk of cross-contact in the kitchen.

Children with food allergies will attend schools just like their nonallergic peers and some planning ahead will help to make the environment safer. Management issues in schools involve methods to prevent relevant exposure to allergens and plans to recognize and treat allergic reactions and anaphylaxis. Physicians should provide written, easy-to-follow instructions in the form of an emergency care plan (ECP), which includes direction on recognizing and treating an allergic reaction including the medication to be given and the appropriate dosing. Parents will need to provide a copy of the ECP to the school staff and inform teachers, nurses, administrators and food service staff about the food allergy. Families should plan to meet with school personnel prior to the start of the school year. Communication with the school about topics such as classroom parties, transportation, supervision in the lunch room if needed, substitute teacher notification, field trips and after-school programs will help to plan food allergy management in all areas of the school environment. FARE has developed a variety of resources and products including a downloadable ECP for physicians to complete and management tips for classrooms and school cafeterias. The Centers for Disease Control and Prevention has published a document entitled Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, a PDF that can be downloaded directly from their website ( www.cdc.gov/HealthyYouth/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf ) or accessed via the FARE website at www.foodallergy.org . Parents, physicians, school administrators, teachers, school nurses, food service staff, and childcare and camp staff will find these resources valuable in the planning required to keep children with food allergies safe. Additionally, the Consortium of Food Allergy Research (CoFAR) has developed and validated an extensive food allergy education program that has free and downloadable patient education handouts on specific allergen avoidance diets, fact sheets on specific food allergic disorders, label reading, cross-contact, restaurant meals, cooking without allergens, nutrition and management issues in schools and camps ( www.cofargroup.org ).

Overview

Fundamental to the care of any infant or child, including those with food allergies, is the assessment of nutritional status. Children with food allergies may have inadequate nutrient intake if the elimination diet is not well designed to substitute for nutrients lost to the elimination diet. Additionally, feeding problems such as food aversion and a limited acceptance of a variety of foods are common in children with food allergies and may significantly contribute to poor energy and overall nutrient intake. Certain food allergic disorders such as eosinophilic gastrointestinal disorders are commonly accompanied by poor appetite and early satiety, which may have an impact on overall nutrient intake. Numerous studies have demonstrated that children with food allergies are at risk of inadequate nutritional intake and poor growth.

A comprehensive baseline nutrition assessment includes gathering, verifying and interpreting data from anthropometric measurements, dietary history, medical history, physical examination and laboratory indices. Additionally, when assessing pediatric nutritional status, eating abilities and competencies must also be determined. Key indicators of potential nutritional risk in children with food allergies are a greater number of eliminated foods or greater nutritional value of eliminated foods, picky or self-selective eating, feeding delays/difficulties, poor variety or volume of foods provided/accepted or an unwillingness of the child to ingest supplemental formula or other substitute foods.

Growth

Several studies have evaluated growth in the pediatric population with food allergy. Christie and colleagues compared height, weight, body mass index and estimates of energy and nutrient intakes in a group of 98 children with food allergy and 99 children without food allergy and found that children with two or more food allergies were shorter, based on height-for-age percentiles than those with no food allergy or only one food allergy. Similarly, Isolauri and colleagues found length and weight-for-length indices in a group of 100 infants with food allergy decreased compared with healthy, age-matched controls. Jensen and colleagues found height for age was significantly reduced in a group of patients living with cow’s milk allergy for more than 4 years when compared with height of parents and siblings as well as normal controls. Additionally, it is possible that children with food allergies may have decreased growth despite adequate nutritional intake. Flammarion and colleagues conducted a cross-sectional study comparing children with food allergies ( N = 96) who had been counseled by a dietitian to paired controls without food allergies ( N = 95). Children with food allergies had weights and heights within the normal range; however, they were smaller for their age than the nonallergic controls, even when they received similar nutrition. Suboptimal nutrition in this population may exacerbate the risk and decreased growth can more easily become poor growth. So while there may be other contributing factors associated with decreased growth in children with food allergy, in general the primary cause of poor growth likely stems from inadequate substitution in the elimination diet.

The NIAID Food Allergy Guidelines recommend close growth monitoring for all children with food allergies. Review of current and historical growth should be completed according to current standards of care that are based on Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) or other national standards. Measurements, including weight, length or height, and head circumference as age appropriate, should be obtained and plotted on appropriate growth charts (WHO charts for infants and children from birth to 24 months and CDC charts for children age 2 to 20 years). Growth typically follows predictable increases in length, weight and head circumference and significant changes in growth velocity are not expected. Plotting growth measurements on the appropriate standardized growth chart will allow assessment of growth velocity for that particular child as well as provide a comparison of growth with the reference population.

Weight for length (under 2 years) and body mass index (BMI; 2 years and older), defined as weight in kilograms divided by the square of height in meters, may be helpful as they take into consideration weight for height. The WHO considers less than the 3rd percentile and greater than the 97th percentile to reflect abnormal growth. The CDC defines underweight in children as a BMI of less than the 5th percentile. Children are considered to be overweight when their BMI is greater than the 85th percentile and obese when their BMI is greater than the 95th percentile.

Dietary Intake Assessment

Dietary intakes can be obtained by 24-hour recall or multiple-day food diary or food frequency questionnaire. A 24-hour recall is generally useful when assessing intake in an infant who is predominantly breastfed or bottle-fed but may provide limited information for older children, as accuracy of a mixed diet may not be reflected with recall. For older infants and children, a food diary will provide a more accurate estimate of intake. A food diary of at least three days (including one weekend and two weekdays) should include the amount and types of foods ingested and the timing of meals and snacks. Questions about typical dietary patterns or food frequency questionnaires may also be used and are especially useful in assessing specific nutrient intakes. For example, assessment of calcium and vitamin D intake may be determined by asking about frequency and amounts of dairy or enriched dairy substitutes consumed.

A registered dietitian will be able to compare dietary patterns to recommendations from the Dietary Reference Intakes (DRI; http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes ) or food group guides specified by the US Department of Agriculture ( www.choosemyplate.gov ) or provided by governmental agencies in other countries. The DRI and other guidelines may be used as a tool to assess nutrient intake, plan interventions and/or monitor the patient’s ongoing nutrient intakes. Even clinicians who are not trained to assess nutrient intake may glean valuable information from a food diary or food frequency questionnaires. For instance, unusual meal or snack patterns such as feeding on demand beyond infancy, or unusual food intakes such as excessive fruit juice consumption may become apparent and give clues to potential causes of poor growth or nutritional status in a child.

Eating Competence

Eating competence describes a child’s ability to eat and enjoy a wide variety of foods of varying flavors and textures that will support adequate nutrition for growth and development. Eating competence and pediatric nutrition are often discussed side by side because feeding problems are common in childhood, with an estimated 25% to 35% of otherwise healthy children affected. Eating is a complex, learned process involving the acquisition of physical skills, behaviors, acquired tastes, and attitudes and feelings about eating in general as well as about particular food items. Even mild, self-selective or ‘picky’ eating can impact nutrient intake and, in combination with an allergen elimination diet, can have serious nutritional implications. Assessment of eating competencies will provide the information needed to provide an effective nutrition care plan. See Chapter 42 for more information on management of feeding problems.

Estimating Nutritional Needs

Energy

The estimated energy requirement (EER) is the average dietary energy intake that is predicted to maintain energy balance. For children, the EER includes the needs associated with the deposition of tissues at rates consistent with good health. There is no established recommended dietary allowance (RDA) for energy because energy intakes exceeding the EER would be expected to result in excessive weight gain. EER can be calculated using the equations provided in the DRI reports ( www.nap.edu ) or by using the interactive DRI calculator for healthcare professionals available on the USDA website ( http://fnic.nal.usda.gov/fnic/interactiveDRI/ ). Energy is provided in the pediatric diet through three major classes of macronutrients: proteins, carbohydrates and fats.

Protein.

Adequate protein in the diet is crucial in all age groups. Many excellent sources of protein are also common allergens including milk, egg, soy, fish, shellfish, peanut and tree nuts. Diets must be carefully planned to meet protein needs when high quality protein sources are eliminated from the diet. Inadequate dietary protein intake may be a contributing factor in the decreased stature reportedly seen in the population of children with food allergies.

Protein needs may be estimated using the DRI for protein found in Table 48-2 . An estimated 65% to 70% of protein needs should come from sources of high biologic value, meaning animal products for the most part, which contain a full complement of indispensable amino acids. Animal products (milk, eggs, meat, fish and poultry) are not necessary to provide optimal protein, but most alternative sources from plants, legumes, grains, nuts, seeds and vegetables do not contain a full complement of indispensable amino acids and therefore greater dietary planning will be required. Additionally, dietary protein recommendations are based on the assumption that energy intake is adequate. If energy intake is insufficient, free amino acids will be oxidized for energy, allowing for less available amino acids for anabolic and synthetic pathways.

TABLE 48-2

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