KEEPING A DIET DIARY
by Del Stigler, M.D.
Pediatrics and Clinical Allergy
Fall 1990 AEHA Quarterly

Food allergies are the most common sensitivities in children, and most children who are allergic at all have some problem with foods.  Tracking down food allergies must begin with careful record keeping in order to discover which foods are the most likely to be causing problems.  This is accomplished by keeping a diet diary.  It should list everything your child eats or drinks, his/her activities, environmental conditions, all symptoms which occur, and times associated with each entry.

Step one, the baseline diet diary, is kept while feeding your child as you usually do, changing nothing in the diet, and should be kept for at least five to seven days.  The baseline diet diary will help your allergist to determine which changes in your child’s diet might be helpful.  The diet diary should be kept throughout all changes in the diet, and as long as the child has any unresolved allergy problems.  Take the diary each time you visit your allergist, even if you have not been specifically asked to do so.  A diet diary will look something like this:

TIME FOOD/DRINK/MEDS ACTIVITIES SYMPTOMS (1-4+)
Night  Sleeping Wet bed
7:30   AM  Awakened Coughing & stuffy nose 4+
8:15   AM Cheerios/milkFrozen orange juiceScrambled egg/butter  
9:30   AM  Watching TV Red cheeks x 1/2 hr.
10:00 AM Apple juice  
12:00        Loose stool
12:30 PM Tomato soupHot dog/ketchupCanned peaches in syrup  
1:00  PM  Playing on grass Runny nose 3+
3:00  PM Cherry KoolaidPotato chips  
3:10  PM   Hyperactive 4+Threw tantrum
4:00  PM  Petting cat 
5:30  PM Fried chickenMashed potatoes/gravy(milk, butter, flour)8 oz.milk 
6:30   PM   Loose stool & red cheeks
7:30   PM Vanilla ice cream  
8:15   PM  Bath 
8:30   PM  To bed Stuffy nose 2+
11:30 PM   Night terror

RECORDING FOODS, DRINKS AND MEDICATIONS
While keeping a diet diary, it is essential that everything your child eats or drinks be listed in complete detail.  Medicines and vitamins should be included.  Ingredients should be listed, and it is also helpful to include brand names.  THIS MEANS YOU WILL HAVE TO READ LABELS, and you will likely be surprised at how much hidden sugar your child is getting, or how many foods contain corn or soy, or other things you thought your child never ate.

When reading labels, watch for derivatives of potentially allergenic foods.  Following are some of the common derivatives:

MILK  butter, whey, casein, caseinate, calcium caseinate, sodium caseinate, dried milk powder or solids, evaporated milk, condensed milk, lactose, cream, buttermilk, margarine, yogurt, lactate, lactalbumin, cheese, curds, whey.

WHEAT bran, wheat germ, bread crumbs, semolina, flour, enriched flour, durum flour, wheat flour, whole wheat flour, gluten, gluten flour, graham flour, malt, farine, modified food starch.

CORN  corn syrup, starch, cornstarch, corn sugar, corn sweeteners, hominy grits, dextrose, malt dextrin, fructose, maize, shortening, vegetable oil, glucose, sorbitol, cerelose.

EGGS  albumin, whole eggs, egg yolks, egg whites, dried eggs, powdered eggs, ovomucin, ovomucoid, vitellin or ovovitellin, meringue, livetin.

Flinstones Chewable Vitamins with Iron
- the daily list can read simply:  “vitamin - purple”

Campbell’s Tomato Soup (contains tomato, milk solids, salt, etc., cooked with milk)
- and the daily list can read simply:  “tomato soup”

RECORDING ACTIVITIES AND ENVIRONMENTAL CONDITIONS
Activities and major weather changes should be included in your child’s diary in order to help determine if environmental factors play a role in your child’s allergies.  Playing outside, petting a cat, falling asleep on the carpet, raking leaves, and so forth, should be noted, as well as wind, rain, a high pollution day, or a hard freeze.  Note also if weeds, grasses, or trees nearby are pollinating.

RECORDING SYMPTOMS
Symptoms to include in the diary are the very things for which you sought help in the first place:  congestion, cough, runny nose, rash, diarrhea, bed-wetting or daytime accidents in an older child, mood swings, etc.  Watch also for red cheeks, character and frequency of stools (color, consistency - seedy, pasty, water, etc.), itching (anywhere), redness around the anus, or behaviour changes.  IF YOU THINK YOU MIGHT BE SEEING AN ALLERGIC REACTION BUT ARE NOT SURE, JOT IT DOWN ANYWAY.

RECORDING TIMES
Times should be noted in the diary for all items listed.  This is important in order to establish which factor was the cause of the reaction.  Foods usually take two to four hours to manifest a reaction, though they may react within minutes.  The reaction may continue until the food is entirely eliminated from the digestive tract - usually three to four days.  Some reactions last only minutes.  Noting the time the reaction was first noticed and how long it lasts is very helpful.  Pay special attention to your child’s condition just before a meal or snack and about 30 to 60 minutes after s/he eats.

FOOD ELIMINATION AND CHALLENGE TESTING
Certain foods may cause reactions that you can easily pinpoint when keeping a diet diary.  Others will not be so clear.  Foods appearing in your child’s diet very frequently may need to be eliminated completely for several days and then challenged to see if they cause a reaction.  ELIMINATE THE FOOD TO BE TESTED FOR AT LEAST FOUR TO FIVE DAYS.  Read labels more carefully than ever, watching for all the hidden sources of the food to be eliminated.  ALL DERIVATIVES IN ANY QUANTITY MUST BE AVOIDED DURING THE ELIMINATION PHASE.

When the food is first eliminated, the child may manifest worse symptoms and beg repeatedly for that food.  These cravings and “withdrawal” symptoms are common when eliminating a potent allergen, and should not alarm you.  This phase usually passes in a day or two, and the child’s symptoms will appear to improve as the allergen is cleared from the body.  The craving will also diminish.  If the child is still in withdrawal after four days, hold off challenging the suspected food until the symptoms are stabilized.  Bear in mind that most children have more than one food allergy, so not all the symptoms will vanish with the elimination of a single food.

After a food has been eliminated for at least four days (but not more than a week), it is time to challenge your child with that food:

1. Feed a normal breakfast which does not contain the food to be challenged.
2. Make sure your child is not coming down with any illness that day.
3. Wait 2 1/2 to 3 1/2 hours after breakfast and feed your child a good-sized serving of the food to be tested.
4. The food should be in pure form - test milk, not cheese or yogurt; cream of wheat, not bread.
5. WATCH CAREFULLY FOR ANY REACTION.
6. If none appears, feed another serving of the food an hour later.
7. Lunch may follow thirty minutes to an hour later, and should not contain the tested food.
8. If no reaction is apparent in the afternoon, the evening meal should contain the challenged food.
9. ONCE YOU SEE A REACTION OCCURRING, DO NOT CONTINUE TO FEED MORE OF THE CHALLENGED FOOD THAT DAY.
10. Note all reactions carefully in the diet diary.

NOTE:  IF YOU HAVE REASON TO BELIEVE YOUR CHILD MAY REACT SEVERELY TO A CERTAIN FOOD, CHALLENGE ONLY AFTER CONSULTING WITH YOUR PEDIATRICIAN/ALLERGIST.  THE ELIMINATION AND CHALLENGE SHOULD BE USED AT HOME ONLY FOR SUSPECTED FOODS THAT ARE REGULARLY IN THE CHILD’S DIET.

If your child reacts severely to the challenge, you may give two to four Alka Seltzer Gold tablets within the first hour to neutralize the reaction.

Once you have pinpointed certain allergies, the food may have to be eliminated entirely for several months, and may then be gradually reintroduced in limited quantity once or twice a week.  There are no hard and fast rules about how much of a given allergen will be tolerated, or how often your child may be fed the offending food.  Please plan to discuss the results of any food elimination and challenge with your pediatrician/allergist before deciding on a treatment plan.

SUGGESTIONS FOR COPING WITH FOOD ALLERGIES
(1) If your child is in school or day care, record keeping will be easier if you send all lunches and snacks with your child and request that s/he not eat or drink anything other than what you provide (plain water may be given).  Enlist the help of day care providers or teachers, if possible, in noting times, activities, and symptoms.  Providing diet diary forms each day with the foods already listed may help to get the cooperation you need.  If the care providers are unable to help with record keeping, spend a few minutes at the end of the day talking with the providers and carefully observing your child.  Write your notes immediately.

(2) Continue to keep your family routine as normal as possible.  Discipline your child as usual.  Giving undue attention to relatively minor reactions may result in you child learning to use allergies for his or her own gratification and will make it more difficult to separate actual sensitivities from normal misbehaviour.  Older children can be taught to report symptoms with good reliability without developing hypochondria.  In most instances, allergies are a health problem like many others - we help the child learn to live as normally as possible, while doing what is necessary in order to stay healthy.

(3) Do not make the mistake of thinking that all behaviour problems or health problems are due to allergies.

(4) Give all of your children positive attention as often as possible.  This will help to eliminate the need for your child to use allergic reactions as attention getters, and will also minimize the jealousy which may occur among siblings when one is “sick” and perceived as getting more attention due to the condition.

(5) Consider making an appointment with a registered dietician who provides nutrition counselling.  S/he can help to analyze the adequacy of the diet if there are a number of eliminated foods, and can suggest substitutes for familiar foods and provide menu and recipe ideas.

(6)   As your child grows and changes, the food sensitivities may change.  Be prepared to begin keeping a diet diary again as soon as you notice a potential allergic problem, and keep the diary current until all symptoms have satisfactorily resolved.  Many parents find it helpful to keep a diet diary even when the child is doing well.  THE DIET DIARY IS THE MOST VALUABLE TOOL AVAILABLE IN TRACKING DOWN YOUR CHILD’S FOOD ALLERGIES, AND YOUR COMMITMENT TO GOOD RECORD KEEPING WILL SAVE YOU TIME AND MONEY IN THE MONTHS TO COME.

Editor’s Note:  The preceding advise applies equally well to adults.  Keeping a food diary is one of the most important rules you can abide by, especially in the early stages of diagnosis.  It enables you to find “patterns” in your symptoms.  The Quarterly is most grateful to Del Stigler, M.D., and Kathleen Dolce, C.H.A., for sending several information sheets currently used in his Pediatrics and Clinical Allergy office in Denver, Colorado.  Our pleasure is increased by the note reading:  Please feel free to publish them in the Quarterly.”