Navigating food allergies and intolerances in children

Food allergies and intolerances in children can be overwhelming for any parent.

WORDS: Laura Freer, Allergy Dietitian

 With at least 1 in 10 infants and 1 in 20 children in Australia affected, it’s important to understand how to identify if your child may have a food allergy/intolerance and take the appropriate steps to manage it. This article, written by one of Adelaide’s most experienced Allergy Dietitians Laura Freer, will explore the most common food allergies and intolerances in Australia and how best to manage them.

Food allergy vs. intolerance: What’s the difference?

Food allergies occur when the immune system mistakenly identifies a harmless food protein as a threat, triggering an immune response. Reactions can range from mild to severe, including anaphylaxis, which is life-threatening. Symptoms usually appear within minutes to hours after consuming the allergen.

Food intolerances happen when the digestive system struggles to break down certain foods or components. This can be due to a lack of specific enzymes, reactions to natural food chemicals, or sensitivity to additives. Symptoms generally appear several hours to days after consuming the food and are less severe compared to allergies.

Common food allergies

1. IgE-Mediated Food Allergies

The most common IgE-mediated food allergens in Australia include egg, peanut, tree nuts (almond, cashew, walnut, hazelnut), sesame, soy, wheat, and shellfish. Peanut allergies are particularly prevalent and can be severe, often persisting into adulthood. It is important to note that any food protein can potentially trigger an allergic response.

Symptoms: rash/hives, angioedema (swelling), gastrointestinal symptoms (nausea, vomiting, diarrhoea, abdominal pain) respiratory symptoms including wheezing, hoarse voice, difficulty breathing and anaphylaxis.

Diagnosis: Allergy testing (skin prick tests or blood tests) can identify specific allergens.

Management: Avoid all forms of the allergen, including trace amounts. Always carry emergency epinephrine (Epipen) and be prepared for potential reactions.

2. Cow’s Milk Allergy (IgE and Non-IgE) 

Cow’s milk allergy (CMPA) is common in infants and young children, involving an adverse reaction to proteins in cow’s milk. CMPA can be IgE-mediated or non-IgE-mediated. 

IgE-Mediated Cow’s Milk Allergy

This involves the immune system producing Immunoglobulin E (IgE) antibodies in response to milk proteins. Symptoms usually appear within minutes to a few hours after consuming cow’s milk and can range from mild to severe.

Symptoms: Reactions can include hives, swelling, vomiting, difficulty breathing, or anaphylaxis.

Non-IgE-Mediated Cow’s Milk Allergy (e.g., Allergic Proctocolitis)

A delayed hypersensitivity reaction where symptoms may appear several hours to days after consuming cow’s milk. It doesn’t involve IgE antibodies and is more challenging to diagnose due to the delayed onset of symptoms.

Symptoms: Vomiting, diarrhoea (possibly with blood or mucus), colic-like symptoms, poor weight gain, or eczema.

Diagnosis: IgE-mediated CMPA is diagnosed with allergy testing. Non-IgE-mediated CMPA is often diagnosed via an elimination diet, where cow’s milk protein is removed from the infant’s or breastfeeding mother’s diet, followed by a controlled reintroduction to see if symptoms return. Healthcare providers may also use symptom diaries and clinical assessments to support the diagnosis.

Management: Strict avoidance of cow’s milk and its products. Breastfeeding mothers may need to avoid cow’s milk, and infants may require extensively hydrolyzed or amino acid-based formulas. An Allergy Dietitian can help with identifying dietary triggers, allergen management, meal planning, and ensuring nutritional needs are met.

Common food intolerances

1. Lactose Intolerance

Lactose intolerance occurs when the body lacks lactase, the enzyme needed to digest lactose, the sugar found in milk and dairy products. It can be primary (born without the enzyme) or secondary (developing after gastrointestinal issues).

Symptoms: Bloating, gas, diarrhoea, and abdominal cramps.

Diagnosis: Typically diagnosed through a trial exclusion diet or hydrogen breath tests.

Management: Limit or avoid lactose-containing products and use lactase enzyme supplements.

2. Gluten Intolerance (Non-Coeliac Gluten Sensitivity)

Gluten intolerance involves adverse reactions to gluten, a protein in wheat, barley, and rye, and is different from celiac disease. 

Symptoms: Bloating, abdominal pain, diarrhoea or constipation, fatigue, and headaches.

Diagnosis: Often diagnosed through a trial exclusion diet and symptom monitoring. Tests for celiac disease may be done to rule out the condition.

Management: Follow a gluten-free diet, avoiding wheat, barley, and rye.

3. Fructose Intolerance

Fructose intolerance occurs when the body has trouble absorbing fructose, a sugar found in fruits, some vegetables, and honey.

Symptoms: Bloating, gas, abdominal pain, and loose stools.

Diagnosis: Hydrogen breath tests or a trial exclusion diet can diagnose fructose intolerance.

Management: Limit high-fructose foods and consider a low-FODMAP diet.

4. Food Additive Intolerance

Food additive intolerance involves reactions to specific additives such as sulphites, MSG, and artificial colourings. 

Symptoms: Headaches, hives, abdominal pain, and asthma-like symptoms.

Diagnosis: Typically diagnosed through a trial exclusion diet and monitoring symptoms.

Management: Avoid foods with specific additives and read labels carefully.

Identifying and Managing Food Allergies and Intolerances

If you suspect your child has a food allergy or intolerance, follow these steps:

• Recognise Symptoms: Observe your child’s reactions after eating certain foods.
• Keep a Food Diary: Record what your child eats and any symptoms. Include details like the type and quantity of food, time of consumption, and reactions. This helps identify patterns and triggers.
• Consult a GP or Paediatrician: They can perform an initial assessment and refer you to an allergist or immunologist for specialised testing.
• Allergy Testing: Skin prick tests or blood tests to identify specific allergens.
• Intolerance Testing: Hydrogen breath tests or elimination diets to diagnose intolerances.
• See an Allergy Dietitian: Dietitians offer crucial support in managing food allergies and intolerances. An Allergy Dietitian can provide personalised advice on managing food allergies and intolerances, including meal planning, suitable substitutes, and preventing nutritional deficiencies. Removing foods from your child’s diet can lead to nutritional deficiencies and growth concerns if not managed properly.
• Follow Management Plans:
• Avoid Trigger Foods: Strictly avoid identified allergens or intolerances. Learn to read food labels.
• Use Substitutes: Incorporate suitable alternatives into your child’s diet for balanced nutrition.
• Emergency Preparedness: For severe allergies, always carry emergency medication like epinephrine (Epipen) and be prepared for potential reactions.

Eating out with food allergies or intolerances

Dining out with food allergies or intolerances requires careful planning and communication 

1. Research restaurants: Look for places with allergen information on their menus or websites. Read reviews from other families with dietary restrictions.
2. Call ahead: Discuss your child’s allergies with the restaurant staff or manager before visiting. Confirm their procedures for avoiding cross-contamination and ask if they can prepare a suitable meal.
3. Communicate clearly: When you arrive, inform your server about your child’s allergies. Provide detailed information and request that separate utensils and preparation areas are used to avoid cross-contamination.

Food substitutes

Finding appropriate substitutes for common allergens can help your child enjoy a varied and nutritious diet. Here are some helpful alternatives:

• Cow’s milk:
• Substitutes: Soy milk, almond milk, rice milk, oat milk, coconut milk. Dairy-free yogurt (coconut/soy), plant-based cheese (soy/coconut), coconut ice cream, chia puddings, dairy-free spread, nutritional yeast (for cheesy flavour).
• Considerations: Ensure substitutes are fortified with calcium and vitamin D for bone health.
• Eggs:
• Substitutes: Pureed apple (1/4 cup replaces one egg), mashed banana (1/4 cup replaces one egg), chia seeds (1 tbsp mixed with 2.5 tbsp water replaces one egg), flaxseeds (1 tbsp ground mixed with 3 tbsp water replaces one egg), commercial egg replacers.
• Usage: These work well in baking and cooking. Pureed apple and mashed bananas add moisture; chia and flaxseeds provide binding. Commercial replacers are formulated for various recipes.
• Peanuts and tree nuts:
• Substitutes: Sunflower seed butter, chickpea spread, sunflower seeds, chia seeds, hemp seeds, pumpkin seeds, tahini paste (Hummus)
• Usage: Sunflower seeds and pumpkin seeds are good for snacks. Add seeds to baking for nutrition and to replace nuts. Tree nut pastes (eg cashew, almond spread) are acceptable if allergic to peanut only.
• Fish and shellfish:
• Substitutes: Chicken, beef, turkey, tofu, legumes, flaxseeds, chia seeds, walnuts
• Omega-3s: flaxseeds, chia seeds, and walnuts provide a good source of omega 3 fatty acids. 
• Wheat/gluten:
• Substitutes: Gluten-free grains like quinoa, rice, millet, buckwheat, and gluten-free oats. Gluten free flours, rice cakes, corn thins, gluten free pasta, and breads.
• Baking: Use a blend of gluten-free flours for better texture and taste in baked goods. Experiment with different combinations to find the best results for your recipes. There are plenty of commercial gluten free products available in supermarkets.
• Soy:
• Substitutes: Coconut aminos (soy sauce alternative), soy-free products (eg soy free bread), calcium-enriched plant milks, coconut yogurt, pea protein.
• Products: Use soy-free versions of foods and consider pea protein as a plant based alternative.

For more resources on food allergies and intolerances, visit:

• Allergy & Anaphylaxis Australia: allergyfacts.org.au 
• Nip Allergies in the Bubs: preventallergies.org.au
• Australasian Society of Clinical Immunology and Allergy: allergy.org.au