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Food allergies in kids are hard enough to manage, so it’s important to have accurate testing done in the first place. Have you checked for food allergies for your kids, but aren’t sure what it all meant? Tried elimination diets to remove the reactive foods, but didn’t see results?

There are many ways the immune system might react to a food. Food allergies are just one type of reaction, among all these different types. Skin prick or scratch tests, IgE food allergies checked with a blood sample, IgG food sensitivity reactions, Mediator Release Testing (MRT), and more – there are many ways to assess food reactions, food allergies, and food sensitivities. If you’ve only screened your child for food allergies with an IgE blood test and/or a skin prick test, and they’re still struggling with food reactions, it’s likely that those are food reactions, albeit of a different sort. More testing can clear the confusion and give a successful path forward.

An example of this that I have seen often in my pediatric nutrition practice is a condition called Food Protein Induced Enterocolitis Syndrome (FPIES). FPIES leaves kids with extremely limited diets and a lot of scary vomiting after eating – so much vomiting that they may need IV fluids immediately. Screening for food allergies is commonly done for these kids by the MD allergist team, but quite often, the IgE reactions (if found) don’t relate to foods that trigger vomiting. This is a frightening condition that usually affects infants and toddlers, though I have had children as old as ten years old in my practice with intractable FPIES, only able to eat three or four foods safely. The missing piece for these kids in each case I have encountered so far – from young infants to school aged kids – is that they all had skewed, imbalanced gut microbiomes. Once this was repaired, vomiting stopped, food became safe, and their diets safely expanded. See more details on my experience with FPIES here.

Generally, MD allergists only address the one type of food reaction that is mediated by immunoglobulin E or IgE. They work to identify the IgE triggers, and then prescribe medications to manage rashes, hives, or anaphylaxis from any exposures. That’s all well and good, and thank goodness for those drugs when we need them!

But what about all the other symptoms and reactions that don’t need the Epi Pen, Zyrtec, steroids, or other drugs? Symptoms that leave your kids feeling lousy with painful gas, bloating, mixed irritable stools that swing between mucousy loose stuff or hard pebbles, chronic stomach aches, migraines, headaches, joint pain, frequent colds or rhinitis, acne, eczema, asthma, rashes that come and go, trouble with focus and attention… All of these can come from reactions to foods. And since an MD allergist will only screen for food allergy, many kids go without deeper diagnosis and continue to feel lousy.

Besides different types of reactions to foods that we can measure with different methods, there are also inter-actions between food and gut microbes. If you’ve experienced gas, bloating, pain or reflux after eating certain foods, this can be due to small intestine bacterial overgrowth (SIBO) rather than the food itself. The microbes in our gut feast first on whatever we eat. Depending on the status of our gut microbiome, foods may cause all sorts of reactions simply by feeding dysbiotic gut flora. Imbalanced gut flora can produce toxins and gas, leading to symptoms like pain, diarrhea, vomiting, bloating or even skin rashes. In many cases, I’ve found that just balancing gut microbiome allows a child to eat a food that was suspect for reaction.

How do you sort it out? First, it can help to understand that there are at least three types of food reactions:

1) Food intolerances: Food intolerances may or may not involve the immune system.

  • Food intolerances can happen without immune response. They can occur simply because we lack enzymes needed to break down certain foods. For example:
    • Lactose intolerance – in this case, the gut can’t break down lactose, the natural sugar in milk. The result is gas, bloating, and diarrhea. Rashes are usually absent (except perhaps diaper rash, from the skin-irritating loose stools). Kids who are lactose intolerant can often manage yogurt, because the lactose has been fermented into its smaller sugar molecules (glucose and galactose). Lactaid products can work too, because the lactose has been enzymatically treated in manufacturing. Harder cheeses, which don’t contain as much lactose as softer cheeses, are often more tolerable too. But kids with true lactose intolerance will often feel badly eating dairy ice cream, fluid milk, frozen custard, gelato, or other products with a lot of milk or softer cheese – all of these still contain lactose.
    • Non-celiac gluten sensitivity: Caused by low enzyme output, this circumstance can permit gluten to be only partially digested. In that case, it end ups as an opioid compound called gliadorphins (from gluten). Gliadorphins can cause all kinds of problems, from constipation, migraines, and anxiety, to addictive picky eating, to expressive language delays and impulsivity. If you’ve got a super picky eater, this may be your problem. Learn more here.
    • Milk protein intolerance: This can have immune involvement (see below), but this can occur in the same fashion as non celiac gluten sensitivity. In this case, casein will be only partially digested into casomorphins, with the same ill effects as are seen from gliadorphins.
    • Phenols and Salicylates: These are compounds in foods that give rich color – from the beautiful natural blue of blueberries to artificial purple in candy and processed food. Without enough enzyme specific for these compounds, kids can become unruly and hyper, with flushing at cheeks or ears, inattention, or aggression.
  • Food intolerances can also happen with immune involvement, when too much histamine is made. In this scenario, IgE or hives to a food can be negative, but tingling, stomach pain, or reflux may ensue. This can be part of mast cell activation syndrome (MCAS). Mast cells are white blood cells that help regulate the immune system and are responsible for histamine release. A human stomach has mast cells scattered throughout its lining, where they play a role in regulating stomach acid secretion. Stomach acid is important – we need strong acid to break down food and prepare it for the small intestine. But, if mast cells are over activated, this can be quite painful and disruptive. In fact, mast cells can be found along all of the GI tract. A variety of conditions – including chronic exposure to a triggering food – can disrupt mast cell function so that too much histamine is released.

2) Food allergies: Food allergies do involve the immune system. They occur when the body creates IgE antibodies to a food, which then trigger the release of histamine and other pro-inflammatory mediators from mast cells each time you eat that food. These reactions are typically rapid, occurring within minutes or hours. An example would be a peanut allergy that causes swelling, hives, and difficulty breathing.

3) Food sensitivities: Food sensitivities also involve the immune system, but not IgE antibodies.

  • Food sensitivities may involve IgG antibodies instead, in which an IgG antibody is made to a food. This can create a delayed reaction that might play out several hours or even a day or two after eating the food. The reaction can be dull pain, loosened stool, explosive stool, mild rash, migraine, behavior changes, bloating, gradual build up of eczema, or mild congestion.
  • Food sensitivities can also occur when white blood cells might react to a food protein, additive, or chemical, and release pro-inflammatory mediators into the bloodstream, which cause symptoms throughout the body. These reactions are often delayed and dose-dependent.
  • An example of either would be a gluten sensitivity that causes stomach aches, diarrhea, or brain fog the day after eating a moderate amount of wheat; a strong behavioral reaction to food colors or artificial ingredients; or eczema that comes and goes, but improves dramatically once a trigger food is removed.[/box]

Any one of, or all of these, can happen at the same time!

Here are my top five expert tips for childhood food allergies and accurate results

I’ve been in pediatric nutrition practice for over twenty years as a licensed registered dietitian nutritionist, and have worked with hundreds of kids with food allergy, food sensitivity, and food intolerances of all sorts. While your doctor may simply tell you what not to eat, it’s my job to tell you what your kids can eat. I have to figure out how much food your child needs, and what food, so they can restore, replenish, and thrive. I aim to reverse or diminish food reactions of all types, if I can, by healing the gut. Here’s what I love to see when working up a new case. These details build a clear baseline and help me understand what foods I will recommend for a replenishing diet. In many cases, I recommend children eat a less rather than more restricted diet; in every case, I aim for including as many foods as possible, rather than eliminating as many as possible.

  1. Get IgE and skin prick testing done with your MD allergist to clarify potentially dangerous offending foods. If there are multiple positives, start only by removing the most serious offenders that are actually life threatening to eat, or that cause significant discomfort (vomiting, hives, diarrhea, stomach pain). If some of the positives are tolerable to eat, keep them in rotation.
  2. If working with your allergist MD doesn’t give resolution or if symptoms persist and food allergy screening was negative, move on to IgG food antibody testing. As above, work with only the top two or three high offenders on your findings. ELISA IgG4 food antibody testing is my preference, and several labs offer this. Although white blood cell media release tests (MRT) are popular, I have found that in my practice with children, MRT is can be an over-sensitive test that doesn’t yield the actionable information I need to organize and build a supportive, growth-worthy food intake for a child.
  3. Remove an offending food completely only if:
    • eating it is life threatening (ER visit, Epi Pen, hives)
    • your child eats it every single day (give the body a break from it for two months to start)
    • your child has significant and noticeable impact from that food. This can mean impact on mood, volatility, attention, sleep, and focus, as well as stomach pain or stool changes that are untenable.
    • always replace a withdrawn food with another one of equal or better nutritional value. For example if replacing cows milk with almond milk, you must add protein and a fat source because there is little protein or fat in almond milk. Use a clean collagen boost and some coconut milk or MCT oil and blend as a shake, or give extra servings of chicken, eggs, avocado, ghee, grass fed beef, or nut/seed butters if safe. You can also ask your provider about elemental formulas if your child has multiple food allergies.
  4. Work with high potency probiotics, especially histamine degrading strains: Lactobacillus reteuri, Lactobacillus salivarius, Lactobacillus rhamnosus to name a few, plus Bifido strains. Start low, with a 10 billion CFU dose daily and if possible work up to 50 or 100 billion CFU daily. Use probiotics year round.
  5. Keep good anti-inflammatory supplements in rotation. These can be used even if your child uses medications like antihistamines or steroids, always let your doctor know:
    • DHA fish oils to 800-2000 mg/day (many liquids available)
    • curcumin and turmeric 400-1200 mg/day
    • D-Hist Junior chewables, 2-6/day (quercetin, N-Acetyl cysteine, nettles, vitamin C)
    • You can find all of these in my FullScript platform, by signing up here.

If you’re using one, give an elimination trial a go for a solid six months. Food proteins like gluten and casein (milk protein) are especially good at triggering all kinds of reactions at the same time, so elimination trials will only work with those proteins if you do it for 4-6 month duration; have zero known cheats including trace amounts in processed foods; also avoid pea protein concentrates at the same time (think Ripple Milk, Daiya cheese, or most “vegan” protein bars, powders and drinks), which look a lot like gluten and casein to the gut; and eat strong replacements for these foods (plain almond milk and French fries won’t cut it!).

If you’ve achieved that, and it’s smooth sailing, go for the re-introduction trial. See how it goes! If you’ve got leaky gut resolved – this is what got the food reactions going to begin with – you won’t see the reactions return. If you’re part of the way there, you’ll see a slow build up of those old symptoms after your child resumes eating the old offenders. In that case, you can judge if you want to continue elimination diet, rotation diet, and/or how much support with anti-inflammatory tools like probiotics you can use ongoing. Good luck and share your experiences below!