The speaker had sole editorial control over the content in this slide deck.

Transcription

1

2 Paediatric Gastro-Allergy Symposium The speaker had sole editorial control over the content in this slide deck. Any views, opinions or recommendations expressed in the slides are solely those of the speaker and do not necessarily represent those of Nutricia.

3 Ruth Stanley Lead Paediatric Gastroenterology Dietitian GNCH

4 Aims Understand Eosinophilic Oesophagitis (EoE) in a nutshell Aware of different dietary treatments for EoE Appreciate the nutritional complexity of a top 6 free diet Realise its not all doom and gloom

5 Eosinophilic Oesophagitis What is it? A chronic immune condition characterised clinically by symptoms of oesophageal dysfunction and histologically by the presence of eosinophils in the oesophagus (1) First presentation 1960, later described as a syndrome 1990 (1) The prevalence of EoE is increasing Unknown numbers in UK Estimated rates of prevalence between cases per 100,000 in population based studies in Europe and USA (1) Past 5 years seen an increase in guidelines and case reports

6 Clinical Presentation Vary with ages, main symptoms (1,2) : Infants and toddlers Feeding difficulties which can result in poor growth Children Vomiting, abdominal or retrosternal pain Adolescences Reflux symptoms, dysphagia and food impaction

7 Treatment Options EoE Combination of medication and dietary manipulation (1,2) Medication PPI Corticosteroids Dietary Exclusive Amino Acid (AA) Feed Targeted Elimination Diet (T.E.D) Top 6 Free

8 Exclusive AA Feed Placed on Exclusive AA feed 6-8 weeks Re-scoped after this period to assess response 95-98% success rate at inducing remission (1) Comes with down sides: Taste Compliance Psychological Cost

9 Targeted Elimination Diet Food avoided based on allergy testing Varying length of time 45-53% success rate at inducing remission (1) High negative predictive value (1, 2)

10 Top 6 free diet Eliminate 6 foods most commonly associated with allergy (IgE and non IgE) Wheat Egg Milk Soya Fish Nuts 72-74% success rate at inducing remission High risk of nutritional deficiency Compliance can be an issue

11 Which dietary treatment Joint decision with consultant Difficult decision with multiple factors to consider Age patient Social support Severity of symptoms Presenting nutritional status

12 Case Study 14 year old boy Clinical presentation of food sticking at each meal and struggling to eat. Histology confirmed EoE. Already on PPI therapy. Weight over 99.6 th Centile, Height 91 st Centile.

13 Interactive Voting Which dietary manipulation option would you choose to place this patient on A Exclusive AA B - T.E.D C Top 6 free diet

14 Case Study continued Asked by consultant to place on exclusive AA to ensure EoE under control by time commence GCSE year at school. Symptoms also severe. During dietetic consultation: Doesn t like Milk or Milkshakes Patient very withdrawn Recently lost grandmother and due to attend bereavement counselling in next few weeks. Mum is extremely anxious Social information: Mum single parent. Patient has older sister on steroids who is currently being treated for depression. Also has 3 younger siblings (triplets)

15 Interactive Voting Which dietary manipulation option would you choose to place this patient on A Exclusive AA B - T.E.D C Top 6 free diet

16 Case Study Treatment in Practice Actual Decision Top 6 free I felt patient would struggle with AA psychologically Very chaotic house hold Nutritional status ok Outcome Unfortunately endoscopy after 8 weeks still showed EoE therefore placed on AA.

17 Principles of a Dietetic Consultation Which foods need to be avoided Suitable alternatives to these foods Practical advice for living on a restricted diet

18 Initial tips for Parents Ask them to look at the tins and packets of food already in their home Make time to go food shopping Provide a list of foods available in major supermarkets and recipes to help plan meals Re-assure them it does get easier

19 Nutritional Deficiency -Macronutrients When food is removed from the diet there is a risk that nutritional requirements will not be met. 12 cases of Kwashiorkor in American children, half due to deliberate food avoidance for suspected allergies without adequate substitution. (3) Children with 2 or more food allergies are shorter based on the population without food allergies (4). Weight and height can be useful and important to monitor overall nutrition

20 In practice Nutritional Deficiency -Macronutrients Unfortunately common for patients to loose weight Food fortification advice Violife cream cheese (48kcal/20g) Oat cream ( 150kcal/100ml) Swap cartons coconut milk (20kcal/100ml) to tinned (170kcal/100ml) Supplements AA based Calogen (add to food) Monitor regularly

21 Nutritional Deficiency -Micronutrients Micronutrients contributed to diet from Top 6 Foods Milk Egg Soy Wheat Nuts Fish Vit A Vit B (all) Vit D Vit E Calcium Phosphorus Iodine Selenium Zinc Folate Iron

22 Nutritional Deficiency -Micronutrients Calcium and vitamin D deficiency can result in osteomalacia and rickets Increasing reports of restricted diets resulting in iodine deficiency and thyroid dysfunction (5) Monitoring Food diary analysis Blood test if possible Try to minimise risk by providing vitamin and mineral supplements. There is limited choice on prescription Increased variety to buy over the counter

23 Labelling EU food labelling laws require labels to clearly state if common allergens are in the food product. Applies to all packaged and manufactured drinks as well as foods sold loose and packed for direct sale May contain / Made in a kitchen containing is often suitable Gluten is ok majority of time - Just avoid wheat Soya lethicin - technically ok but advise to avoid all sources to make more practical

24 Alternative Foods Good range of foods in supermarkets. Free from aisles (still double check labels) normal aisles have plenty of options Aware of hidden sources of foods check labels Fussy eaters top 6 free diet is still achievable (just a little harder)

25 Milk Main Foods Missed Prescribed age appropriate Rice, coconut and oat milk, look for added nutrition Bread B-free, ENRG, Schar Wraps and bread rolls often better tolerated. Cake/biscuits Make own cornflake/rice-krispie bars with moo free chocolate/marshmallows Biscuits better choice Flap jacks/oat bars (toddler food range)

26 Main Foods Missed Chocolate Moo Free (good website) Crisps Mainly younger children wanting bite and dissolve textures Skips suitable Corn based Gravy Can make own using meat juices and corn flour Tesco free from gravy

27 Economical Can be expensive Top 6 Free suitable food Non restricted diet food Bread 3 (400g loaf) 1 (800g branded loaf) Milk 1.40 (1L) 0.75 (1.1L cows milk) Pasta 1.20 (500g) 0.59 (500g) Online shop for 3 days following top 6 free diet = 22. Buying same products for a non restricted diet = 13.50

28 Economical Advice: Bulk buy suitable foods when reduced and freeze Try to buy most of the food from normal aisles Base meals around foods that are naturally suitable (meat, potatoes, rice etc.) Ask GP to prescribe a small amount of suitable products each month This is GP discretion and therefore not guaranteed

29 Cooking Good cooking skills are helpful (remember that not everyone has these or the confidence to try making new food) Supply basic recipes to help. After a few weeks parents tend to find that their cooking skills and confidence with new foods improve. Currently looking at setting up top 6 free group cooking sessions

30 Eating away from home - Schools Send with packed lunch if possible. provide parents with a range of ideas for example: Sandwich, crisps, fruit, coconut based yoghurt Pasta in a tomato sauce (cold), jelly, cereal bar Parents to speak to school catering about dietary restrictions. If any problems, dietitian can phone and speak to catering staff Send child to school with plenty of suitable snacks If receive school milk, consider sending own little carton of suitable milk

31 Eating away from home - Parties and Restaurants If going to a party take own food If child regularly goes to a friends house for meals, consider proving friends parents with suitable foods to keep in their house If eating out, phone restaurant or look online at menu beforehand to see if can cater for a top 6 free diet Most of the main chain restaurants should be able to cater. Check social media for independent restaurants.

32 Eating out examples Pizza Express Gluten free dough balls Gluten free pizza (no cheese) meat and veg topping Sorbet Nandos Any marinated chicken Sweetcorn +/- chips or sweet potato wedges Mexican style ice-cream McDonalds Burger no bun Chips/fruit sides

33 Conclusion Top 6 free diet can induce remission in the majority or patients with EoE Following a top 6 free diet can be difficult and limiting however providing patients with education and tips can help children to feel less isolated and excluded Important to check nutritional status of patients and monitor regularly

34 References 1. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. Lucendo, Alfredo J, et al. 0, 2017, United European Gastroenterology Journal, Vol. 0, pp Management guidelines of eosinophilic esophagitis in children. Papadopoulou, A, et al. 1, s.l. :ESPGHAN EoE Working Group/GI Committee, 2014, JPGN, Vol 58, pp Kwashiorkor in the United States: fad diets, percieved and true milk allergy, and nutritional ignorance. Liu T, Howard RM, Mancini AJ, Weston WL, Paller AS, Drolet BA, et al. Archives of dermatology. 2001; 137(5): Epub 04/04/ Growth and Nutritional Concerns in Children with Food Allergy. Mehta H, Groetch M, Wang J. Curr opin Allergy Clin Immunol. 2013; 13(3): Dietary restriction causing iodine-deficient goitre. Cheetham T, Plumb E, Callaghan J, et al. Arch Dis Child Published online First: