I have a 27yo patient with moderate MR (unable to verbally communicate), cerebral palsy, seizure disorder, and dysphagia who lives in a home in state custody referred for evaluation of food allergy. When entering the home 2 years ago, mother reportedly gave a history of itching and hives upon ingestion of strawberry, pineapple, milk, egg, peanut, flounder, pecan, and pork. No further is known about this and the current history is provided by the head nurse and a hired caregiver.

The question arose when it came to someone's attention that hired caregivers in the home were feeding her pudding, yogurt, cheese, foods with baked milk, egg, tilapia, salmon, unnamed white fish, almond milk and pork. It is reported that she has tolerated these foods without any change from her baseline or observed reaction such as rash, etc. However, staff is concerned that she may be experiencing or will experience an unrecognized reaction that the patient will not be able to communicate and is looking for recommendations in regard to what she can/can't eat.

My inclination was to recommend the following: she can continue to eat what has been observed to be tolerated (cow's milk, egg, pork). And continue to eat those fish (tilapia, salmon, the unnamed white fish) and almond milk tolerated but avoid flounder and pecan since these are the ones she reportedly did react to and haven't been eaten since, and do not introduce new fish or tree nut into the diet due to risk of cross reactivity. Avoid strawberry, pineapple, and peanut also since these reportedly were foods she reacted to and have been avoided since.

Even though she can't verbally communicate due to her degree of MR, I feel it is unlikely she is experiencing a reaction if there is no observable change in her baseline behavior (as the staff had concerns might be happening but not witnessed) or observed reaction.
I was wondering how you would proceed in this case and counsel the staff/caregivers. Would you proceed with immunocapRAST testing to these foods? I felt skin testing and food challenging in her case would not be advisable, challenging and pose additional risk due to her MR.


Thank you for your inquiry.

I think your strategy is probably appropriate and certainly safe. There is, however, one thing I would consider. I would have a dietitian (hopefully one is available at her residence home) review this diet to make sure that it is nutritionally adequate. If it is, since I assume the patient cannot express any desire for other food, I would see no reason to proceed further. If, however, the dietitian felt that additional food(s) was/were needed for nutritional reasons, then I would perform a serum-specific IgE to the food(s) requested, and pending those results, consider an oral graded food challenge.

Thank you again for your inquiry and we hope this response is helpful to you.

Phil Lieberman, M.D.

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