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International Journal of Food Sciences and Nutrition
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iijf20
Nutrient intake in school-aged children with food
allergies: a case-control study
Enza D’Auria, Erica Pendezza, Alessandro Leone, Francesca Riccaboni,
Alessandra Bosetti, Barbara Borsani, GianVincenzo Zuccotti & Simona
Bertoli
To cite this article: Enza D’Auria, Erica Pendezza, Alessandro Leone, Francesca Riccaboni,
Alessandra Bosetti, Barbara Borsani, GianVincenzo Zuccotti & Simona Bertoli (2022) Nutrient
intake in school-aged children with food allergies: a case-control study, International Journal of
Food Sciences and Nutrition, 73:3, 349-356, DOI: 10.1080/09637486.2021.1975658
To link to this article: https://doi.org/10.1080/09637486.2021.1975658
Published online: 09 Sep 2021.
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INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION
2022, VOL. 73, NO. 3, 349–356
https://doi.org/10.1080/09637486.2021.1975658
STUDIES IN HUMANS
Nutrient intake in school-aged children with food allergies: a
case-control study
Enza D’Auriaa, Erica Pendezzaa, Alessandro Leoneb , Francesca Riccabonia, Alessandra Bosettia,
Barbara Borsania, GianVincenzo Zuccottia and Simona Bertolib
a
Pediatric Department, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy; bInternational Center for the Assessment of
Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS), Universita di Milano, Milan, Italy
ABSTRACT
ARTICLE HISTORY
Most studies assessed nutrient intake of young children with food allergy (FA) compared to
healthy children. We aimed to compare macro- and micronutrient intake of school-aged children
with FA to non-allergic children. This case-control study included 93 Italian children (52 with FA
and 41 controls, median age 7.5 and 8.3 years, respectively). Macro- and micronutrient intake
was assessed by a three-day food dietary record. Anthropometric measurements were also collected. The median height z-score was significantly lower in the FA group, despite a similar daily
energy and protein intake. Calcium, iron and vitamin D intake was suboptimal in both groups,
while protein intake was higher than recommended in both groups. Unexpectedly, children with
FA consume more protein than controls, while having lower micronutrient intake, especially calcium. Our data suggest the importance of nutritional counseling for children with FA to ensure a
balanced nutrient intake while on elimination diet.
Received 5 May 2021
Revised 24 August 2021
Accepted 30 August 2021
Introduction
Food allergy (FA) is an adverse immune reaction,
which may be immunoglobulin E (IgE) and non-IgE
mediated, and occurs reproducibly after exposure to a
given food (Boyce et al. 2010). Symptoms can vary
from mild to severe and, in rare cases, can lead to
anaphylaxis, a potentially life-threatening allergic reaction (Boyce et al. 2010).
The exact prevalence of food allergies is unknown,
as it varies according to the diagnostic method used,
the study methodology and the geographic area
investigated.
In the United States, it is estimated that 8% of children have FA, 2.4% have multiple food allergies, and
approximately 3% experience severe reactions (Gupta
et al. 2011). In Europe, the estimated prevalence of
FA in school-aged children is between 1.4% and 3.8%
(Grabenhenrich et al. 2020). The main allergens are
cow’s milk, hens’ eggs, soy, peanuts, tree nuts, wheat,
fish and shellfish, accounting for more than 90% of
childhood cases of FA (Sicherer and Sampson 2006).
The mainstay treatment is the avoidance diet,
which involves careful avoidance of the causative
allergen (Yu et al. 2016). The elimination of foods
from the diet may lead to feeding difficulties, such as
CONTACT Enza D’Auria
[email protected]
ß 2021 Taylor & Francis Group, LLC
KEYWORDS
Food allergy; nutrient
intake; growth;
micronutrients; school
aged children
food aversion and anxiety, and poor dietary choices,
such as replacement of nutrient-dense allergenic foods
by foods that are not nutritionally equivalent (D’Auria
et al. 2019). As a consequence, children with FA may
be at higher risk of suboptimal energy intake, macroor micronutrient deficiencies and impaired growth
(Venter et al. 2012; 2018).
The main goal in the management of food allergy
is to avoid the offending foods while providing an
adequate, healthy and nutritionally balanced diet
(Venter et al. 2012; Meyer 2018; D’Auria et al. 2020).
Some studies have examined the impact of avoidance
diet on children’s growth, with conflicting results.
Children with cow’s milk allergy (CMA) and multiple
food allergies seem to be at higher risk of impaired
growth and inadequate nutrient intake (Isolauri et al.
1998; Vieira et al. 2010; Sova et al. 2013; Tuokkola et
al. 2017; Meyer 2018).
A recent international survey on the growth of children with FA confirmed that low height-for-age is
more common than low weight-for-age (Meyer et al.
2019). Growth impairment has been reported in some
allergic children, despite a similar energy and protein
intake to healthy controls (Flammarion et al. 2011).
However, other studies found no impact on growth,
Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
350
E. D’AURIA ET AL.
even in children with multiple food allergies (Meyer
et al. 2014; Berry et al. 2015; Meyer et al. 2016;
Venter et al. 2017). A retrospective study found no
difference in growth between children with FA and
healthy children irrespective of the number of foods
eliminated, except for children with CMA (Mehta et
al. 2014). These conflicting results may be due to the
variability of the studies’ inclusion criteria and methodologies (e.g., age, number and type of food allergies,
presence of comorbidities, and the growth references considered).
In regard to nutrient intake, most studies in literature found reduced energy intake, with lower intake
of key macronutrients such as fats (Henriksen et al.
2000) and proteins (Tiainen et al. 1995; Isolauri et al.
1998; Robbins et al. 2014). Given their presence in
cow’s milk (one of the main food allergens in children), calcium and vitamin D are among the most
studied micronutrients, and low vitamin D levels and
suboptimal calcium intake in children with FA have
been reported by several authors (Henriksen et al.
2000; Christie et al. 2002; Medeiros et al. 2004; Foong
et al. 2017).
Few and contrasting data are available on other
micronutrients. Some studies reported a reduced
intake of riboflavin, niacin (Henriksen et al. 2000) and
iodine (Thomassen et al. 2017), while others found
intakes (e.g., for niacin) actually higher than the tolerable upper level (Robbins et al. 2014).
In a cross-sectional study of adolescents and adults
with food allergy, Maslin and colleagues concluded
that the nutrient intake of the allergic group was similar to, or in some cases better than, that of controls
(Maslin et al. 2018). In a preliminary report, we also
did not find any disparities in energy and macronutrient intake between children with and without FA
(D’Auria et al. 2019).
The aim of this study was to assess macro- and
micronutrient intake in children with FA in comparison to a control group.
Materials and methods
Study design
We conducted a case-control study of children with
FA (FA group) compared to healthy children (control group).
The FA group was recruited from children who
had been referred to the Vittore Buzzi Children’s
Hospital Allergy Unit (Milan, Italy) between May
2017 and December 2019.
All children suspected of having FA underwent a
complete diagnostic work-up including a confirmatory
oral food challenge (OFC), except for cases with a history of anaphylaxis. Only children with a confirmed
diagnosis of IgE or non IgE-mediated allergy to one
or more foods were enrolled in the study.
During the same period, a control group was
selected from healthy children attending International
Centre for the Assessment of Nutritional Status
(ICANS) University of Milan for nutritional status
assessment screening.
The exclusion criteria were the presence of known
acute (e.g., influenza) or chronic diseases (e.g., coeliac
disease or diabetes), restricted diet and any pathological conditions with dietary implications. All children underwent a nutritional assessment, during
which anthropometric measurements were taken, and
their parents were given a three-day food dietary
record to complete. Among the 54 FA children
enrolled, 2 (3.7%) failed to complete the 3-day dietary
record, and they were not included in the analysis.
Similarly, among healthy children, of the 49 initially
enrolled, 8 (about 16%) did not return the completed
diary. A total of 93 children (52 with FA and 41 controls) were then evaluated. The study was performed
in accordance with the Declaration of Helsinki and
the parents of each child gave their written informed
consent. The study protocol was approved by the
Ethics Committee of Milan Area 1 (2018/ST/267).
Anthropometric measurements
Anthropometric measurements were collected by
trained dietitians and nutritionists following standard
guidelines (Lohman et al. 1988). Body weight was
measured to the nearest 100 g with a beam scale, with
the subject wearing light clothing. Body height was
measured to the nearest 0.1 cm using a vertical stadiometer. Body mass index (BMI) was calculated as
weight (kg)/height (m)2.
WHO reference data were used to calculate the
standard deviation scores (SDS) for weight, height
and BMI.
Nutrient intake
Nutrient intake was estimated using a prospective
three-day food dietary record. Parents were instructed
by an expert dietitian on how to complete the dietary
record for two non-consecutive working days and one
weekend day.
INTERNATIONAL JOURNAL OF FOOD SCIENCES AND NUTRITION
Every food item or beverage consumed during the
day had to be reported, specifying the time and the
amount consumed, along with a detailed description
of the food item. For packaged items, parents were
asked to indicate the brand name and product details;
for homemade foods, they were asked to record the
ingredients (including weight), the recipe and the
cooking method. Any leftovers also had to be
weighed, and the weights reported in the dietary record.
Where food or beverage weighing was not possible,
parents were trained to quantify them using common
kitchen utensils, such as glasses, spoons or bowls.
Once returned, every three-day dietary record was
checked for completeness by two independent dietitians; in case of missing details, participants were contacted by telephone to complete the filling.
Energy, macronutrient intake (protein, carbohydrates, and fats) and micronutrient intake (vitamins
and minerals) were estimated using the three-day dietary record and by using the Metadieta software
(Me.Te.Da. S.r.l., San Benedetto Del Tronto, Italy).
The nutrient intakes were compared to the recommended intake for sex and age according to the
Italian Reference Nutrient Intakes (RNI) (Societa
Italiana di Nutrizione Umana 2014).
Statistical analysis
Most continuous variables were not Gaussian-distributed, and all are reported as median (50th percentile),
and interquartile range (25th and 75th percentiles).
Discrete variables are reported as the number and
proportion of subjects with the characteristic of interest. Between-group comparisons were performed with
the Wilcoxon-Mann-Whitney test for continuous variables and with the Fisher’s exact test for discrete variables. A p value
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