Food Allergies: How to Diagnose and What to Feed a Child Who Has Them

Breezy Mama Adrian came to us recently for menu ideas for her niece who is allergic to many foods. We turned to two experts — Cynthia Epps, MS, IBCLC of MotherWork in Santa Monica California and Nicole Meadow, MPN, RD from Nutrition Wise (and a mom of a child with allergies) — to find out not only how to diagnose a child’s food allergy, but to also get great cookbook suggestions and Web sites to help with meal and snack ideas.

How do parents find out if their kids have allergies and what signs should they look for?

CYNTHIA: Skin rashes, chronic eczema and diarrhea following the ingestion of any of the offending foods usually signals a food intolerance. A long time runny nose that never seems to clear up may indicate a food intolerance and/or mild allergy. Frequent colds and/or ear infections (averaging one per month after one year of age) may also be indicative of an underlying food intolerance or mild allergy. Age is a factor, along with the family history. [In the case of] infant’s, [their] digestive system simply may not be mature enough to handle the various proteins, peptides, and carbohydrates of the offending food. Once the infant is exposed, the risk of developing a true food allergy increases with subsequent exposure to the offending food.

A true food allergy is a different problem. Symptoms may be flagrant and vary. There can be an immediate reaction, such as hives around the face and on the body, within one hour of eating the food. Sometimes the reaction may be delayed for up to 4 to 8 hours after ingestion. Reactions can be minor, such as throat or mouth irritations; or, there may be stomach cramps or nausea followed by vomiting. In more severe reactions, there can be respiratory symptoms, such as coughing or wheezing, and in some cases, asthmatic symptoms. In severe cases, the reaction may be anaphylactic – immediately causing the child’s respiratory system to fail. This reaction is widely feared and considered a true medical emergency. Yet, the prevalence of true food allergies in the general pediatric population is only 6 to 8 % in children less than 4 years old. This means that if the parents suspects their child has a food allergy, it may be only an intolerance that he/she will outgrow in time, usually after their third birthday.

If suspected, what steps should a parent take next? What is the best place to find an allergist specialist in their area?

CYNTHIA: If a parent suspects a food allergy, the obvious next step is to eliminate the suspect food or foods from your child’s diet. True elimination means deleting only one food at a time from the child’s diet over a period of two weeks. If during this time the child shows improvement, the parent may have correctly identified the offending food. It can be that simple. One does not need to remove all suspected foods from the child’s diet at the same time. The principle of checking the highest allergen prone foods one at a time allows the parent to provide alternatives for your child while continuing to feed them a balanced diet.

What is involved in the testing to determine what the child is allergic to?

CYNTHIA: If, after trying the elimination diet the child is still symptomatic, the parent may contact a pediatric allergist for a RAST test. The RAST (radioallergosorbent test) is the most commonly used method to pinpoint food allergens. It provides information similar to a simple skin prick test. Currently, the RAST test is excellent for predicting a true allergy to the most common offending foods: milk, eggs, peanuts, and soy. When the test results are negative, there is a 95% degree of accuracy. But when they are positive, the accuracy still falls short to 50%. This means that a positive response can happen long after the child has outgrown the food allergy. The best indicator at this point is to follow the RAST test with a food challenge. The parent may offer the child the suspected food and observe his/her reactions. This can be done at home, providing the child’s reactions are relatively mild and not life-threatening. But if parent suspects a true allergic response, the food challenge should be done only under a physician’s supervision.

Once parents are aware of the allergy, what do they do in case of emergency?

CYNTHIA: It is always a good idea for parents to keep a bottle of over-the-counter dye-free Benedryl on hand, when dealing with suspected allergic children. In the case of severe allergies, it is recommended for parents to request for an “epi-pen” – which can stop a life-threatening reaction – from their pediatrician by prescription only. Pediatric allergists can be located through the American Academy of Pediatrics on-line listings for specialists by area.

Should pregnant women avoid certain foods?

CYNTHIA: For prevention, some studies show that pregnant women who completely eliminate cow’s milk and all dairy products, eggs, fish and peanuts from their diet starting by the tenth week of pregnancy and during lactation, substantially reduce the risk that their baby will develop allergies/sensitivities in the first year of life. One study showed a reduction from a 60 percent risk to a 15 percent risk for babies with two allergy-prone parents. Because food additives are also suspected of causing food reactions, an additive-free diet for the nursing mom until her baby is six months old may also help.

What about when breast feeding?

CYNTHIA: Breast feeding women can reduce and/or eliminate the risk of creating food allergies by removing the offending foods from their diets. It often takes two weeks before you can see a change in your baby. The most common foods causing and intolerance or allergy through breast milk are: cow’s milk, peanuts, wheat and chocolate. It is also a good idea for each family to consider their individual family history. If there is a clear sensitivity to these foods in either the mother or father, eliminating them for the duration of breastfeeding can lower the risk of an allergy developing in your baby.

The best defense against food allergies, is to avoid exposing the infant’s gastric system to the most common offenders, prior to one year of age.  Solid foods, when introduced too early, can precipitate a sensitivity or allergy in an otherwise healthy baby.  This is due to normal human infant gastric physiology — the baby’s gastric tract is, by analogy, open like a tea strainer during the first 12 months of life.  This is to facilitate the rapid growth we see in the human infant from birth through 12 months of age.  Although the infant’s gastric tract is routinely described as “immature”, it is ideally designed to facilitate the rapid transfer of nutrients from the baby’s intestines into the blood stream to promote rapid growth. Hence, just one taste is all it takes in many children under the age of six months to develop a food allergy/sensitivity.

What steps do you recommend to help avoid allergies when introducing solids to babies?

CYNTHIA: If a parent suspects their child is at risk for a food allergy, there are several options through dietary management. First, they may delay the introduction of solids until their infant is at least six months old (age-corrected for preemie babies). Although the timing of starting solids continues to be a topic of debate among pediatricians, UNICEF, The World Health Organization (WHO), and The American Academy of Pediatrics recommend waiting until the infant is six months old. The positive effects of waiting lowers the incidence of infant illness and/or allergies, plus heightens the protective effects of breastfeeding in both the infant and the mother. Infant digestive enzyme activity also continues to mature between four to six months, helping to reduce the complication of possible food allergies.

Secondly, parents can minimize allergies by introducing solid foods slowly. Baby cereal, fortified with iron, has been universally recommended by most pediatricians as the very first solid food. Recent research shows that parents may start with green or yellow vegetable purees instead of the traditional rice cereal, to lower the risk of infant constipation and/or food sensitivities or allergies. Parents may proceed to pureed peas, sweet potatoes, and carrots, followed by apples, pears, and/or prune puree. Carrots, beets, green beans, squash, turnips and collard greens should not be home prepared for your infant before 8 months of age due to the possibility of nitrate poisoning. Between eight and ten months, these vegetables can be safely home-cooked and offered along with grains and fruits, as part of a balanced meal pattern. Egg yolk (separated from the egg whites) is a good source of iron, protein and healthy fat for the infant 10 months of age. Cow’s milk, yogurt, and cheeses are best avoided until your child is over 12 months of age. Depending upon the family history, parents may delay all grains until 8 or 10 months of age. Simple avoidance of wheat products and wheat cereals until after ten months can lower the risk of creating a food sensitivity.

What are the big food offenders?

CYNTHIA: The top offenders are cow’s milk/dairy products and soy proteins. Eggs, peanuts, wheat, tree nuts and shellfish account for approximately 90% of the food sensitivities in children in the United States. Exposure may occur as early as one bottle of cow’s milk-based infant formula, or a routine vaccine grown in albumen – aka ‘egg white’ – mixtures by laboratories which can precipitate an “chicken/egg” allergy in the older infant/toddler. Also listed among the common food allergens are walnuts, pecans, cashews, pistachios, hazelnuts, and almonds, dried beans and bean products, including soybeans and soy milk. Less common causes of food allergies are the early introduction/exposure to whole wheat (pasta/breads), citrus fruits, tomatoes, and strawberries, chocolate, mushrooms (fungi), food additives such as tartrazine, sulfites, monosodium glutamate, benzoates), pesticide residues on vegetables and fruits, and hormone residues in milk, beef, chicken, pork, turkey (animal products).

Can you recommend the best foods for kids who have them?

CYNTHIA: For hypoallergenic infants, simple foods in their nature states – organic grains, vegetables and fruits, free-range chicken, turkey, pork, beef, and organic soy or tofu products.

NICOLE: The best foods for kids who have allergies depends on their individual allergies. All children should be offered several small meals and snacks throughout the day in order to receive the nutrients that they require for their growing bodies. Offering 3-4 food groups at meals (protein, grain, fruit or veggie and a calcium source) at meals and 2 food groups at snacks helps to ensure that all of their bases are covered. Remember that it is YOUR job as a parent to offer the food but is your CHILD’s job to decide if they are going to eat and how much. Often times children with food allergies might have co-morbidities from having to omit multiple foods so make sure that you notify your health care provider if your child is not gaining weight, gains too much weight, seems to not want certain types of textures (sensory issues with foods), has constipation or diarrhea or starts to have a control issue about their food.

a. If your child is allergic to milk (and is over 1 year of age), try almond milk, soy milk, rice milk, hemp milk or other calcium fortified foods like calcium fortified orange juice, broccoli, almonds, beans, kale, spinach and tofu.

b. If your child is allergic to eggs or nuts, make sure that they get other sources of protein like from lean meats, (eggs or nuts, depending on which they are allergic to) tofu and beans.

c. If your child is allergic to fish or shellfish, make sure they have a source of omega 3 fatty acids like from flax oil or talk to your health care provider about supplementation.

Any great cookbook recommendations?

NICOLE: Time to get cooking! For many children with multiple food allergies, the combinations don’t allow for many packaged foods at all. Not to worry… it is actually a blessing in disguise! This allows your child to have a fresh diet and be exposed to many different flavors and textures that they might not have if they didn’t have their allergies (its always important to look on the bright side. Right? That’s how I view my son’s multiple severe food allergies). Here are some of my favorite food allergy cookbooks, but remember, you can always use a regular cookbooks and make substitutions (for example, use egg replacer for eggs or a milk substitute for milk, etcetera).

a. What’s To Eat: The Milk-Free, Egg-Free, Nut-Free Food Allergy Cookbook by Linda Coss
For Amazon’s price of $11.53 (vs. $16.95), click here to purchase.

b. What Else is to Eat? The Dairy-, Egg-, Nut-Free Food Allergy Cookbook by Linda Coss
For Amazon’s price of $11.53 (vs. $16.95), click here to purchase.

c. Sophie Safe Cooking: A Collection of Family Friendly Recipes that are Free of Milk, Eggs, Wheat, Soy, Peanuts, Treenuts, Fish and Shellfish by Emily Hendrix
For Amazon’s price of $15.25 (vs. $16.95), click here to purchase.

d. Great Foods Without Worry: More than 90 Delicious Recipes without Wheat, Eggs, Nuts, Dairy, Soy or Gluten by Cindy Moseley
For Amazon’s price of $11.01 (vs. $12.95),click here to purchase.

e. The Incredible Edible Gluten-Free Foods for Kids by Sheri L. Sanderson
For Amazon’s price of $13.57 (vs. $19.95), click here to purchase.

As a pediatric dietitian and a mother with a child with allergies, what other advice do you have for moms?

NICOLE: As a dietitian and as a mom of a child with multiple severe food allergies, I believe that it is important to make sure that your children understand their food allergies so that they stay safe but also not feel too different and this is a fine line! Make sure to always have an alternative for your child at parties or in school so that they are included… talk to the teachers or other parents so that you can be prepared. Talk to your children and see if they have any questions about their allergies, it is better for them to talk to you and ask you questions then for them to sit and worry or wonder. If you feel overwhelmed, join a local support group for parents with children with food allergies, it has been such a help for me!

How do parents convey to their child they must avoid certain foods? Do you have a children’s book recommendation?

NICOLE: Open the dialogue with your children early… show them pictures of what the foods look like so that they know what to avoid. Use books like “The Peanut Free Café” (click here to purchase) or “How Lenny Found out About his Food Allergy” (click here to purchase). Make the conversation positive by telling your kids which foods are “safe” instead of always telling them which foods they can’t have/which foods they are allergic to.

Can you recommend the best places to shop for allergy friendly food? Are there websites you recommend where people can order and/or get great options and recipes too?

NICOLE: There are so many places popping up which cater to individuals with one or more food allergies… here are some of my favorites!
a. www.enjoylifefoods.com
b. www.chebe.com
c. www.gakssnacks.com
d. www.pitterpatties.com
e. www.ener-g.com
f. www.iansnaturalfoods.com
g. www.bobsredmill.com
h. www.authenticfoods.com (gluten free)
i. www.kinnikinnick.com
j. www.pamelasproducts.com
k. www.allergyfreeshop.com

l. And for general information:
i. www.foodallergy.org
ii. www.allergykids.com
iii. www.kidswithfoodallergies.org
iv. www.epipen.com

About Cynthia and Nicole
Cynthia Epps, MS, IBCLC, is a metabolic nutritionist and board certified lactation consultant in private practice in the Los Angeles area. She trained at UCLA, the Pump Station in Santa Monica, the Cedar-Sinai Medical Center and The Lactation Institute in Los Angeles. Her practice includes in-home lactation consults, transitioning to solids, and gentle weaning. Her mission is to teach teaching new mothers how to navigate the first year of motherhood while giving themselves and their babies the very best start in their new lives together. To contact Cynthia, email Motherwork2001@aol.com

Nicole Meadow, MPN, RD is a reputable professional in the field of pediatric nutrition. Her clients are referred for a variety of nutritional concerns including food allergies, diabetes (type I, II and gestational), celiac disease, feeding disorders, failure to thrive, cardiac disease, eating disorders, and others. Nicole works with both typically developing children and children with developmental disabilities. For more information, click here.

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