Food Allergies


Article Author:
Claudia Lopez


Article Editor:
Magda Mendez


Editors In Chief:
Chaddie Doerr


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 8:38:26 AM

Introduction

Food allergy is defined as an immune reaction to proteins in the food and can be immunoglobulin (Ig)E-mediated or non–IgE-mediated. IgE-mediated food allergy is a worldwide health problem that affects millions of persons and numerous aspects of a person’s life. Allergic reactions secondary to food ingestion are responsible for a variety of symptoms involving the skin, gastrointestinal tract, and respiratory tract. Prevalence rates are uncertain, but the incidence appears to have increased over the past three decades, primarily in countries with a Western lifestyle.[1][2][3]

Etiology

Food allergy can have 2 etiology depending on the mechanism of disease: IgE-mediated or type I hypersensitivity and other immunologically non-IgE mediated reactions.[4][5]

Epidemiology

About 6% of children experience food allergic reactions in the first three years of life, including approximately 2.5% with cow’s milk allergy, 1.5% with egg allergy, and 1% with peanut allergy. Studies have shown that peanut allergy prevalence increased over the past decade. Most children tend to outgrow milk and egg allergies by school-age. In contrast, children with peanut, nut, or seafood allergy retain their allergy for life.[6][7]

Pathophysiology

In predisposed persons exposed to certain allergens, IgE antibodies specific for food are formed that bind to basophils, macrophages, mast cells, and dendritic cells on Fc epsilon receptors. Once food allergens enter the mucosal barriers and reach cell-bound IgE antibodies, these mediators are released and cause smooth muscle to contract, vasodilation, and mucus secretion, which result in symptoms of immediate hypersensitivity (allergy). Activated mast cells and macrophages that attract and activate eosinophils and lymphocytes release cytokines. This leads to prolonged inflammation, affecting the skin (flushing, angioedema, or urticaria), respiratory tract (rhinorrhea, nasal pruritus with nasal congestion, sneezing, dyspnea, laryngeal edema, wheezing), gastrointestinal tract (nausea, oral pruritus, vomiting, angioedema, abdominal pain, diarrhea), and cardiovascular system (hypotension, loss of consciousness,  dysrhythmias) as per the Nelson Textbook of Pediatrics.[8][7]

History and Physical

Clinical Manifestations

According to the predominant target organ and immune mechanism, it is most useful to subdivide food hypersensitivity disorders (Table 1).

Table 1- Symptoms of Food-Induced Allergic Reactions

Gastrointestinal

Food allergies that cause gastrointestinal manifestations are often the initial form of allergy to affect infants and young children, causing irritability, vomiting or “spitting-up,” diarrhea, and poor weight gain. There are three main entities related to food allergies associated with gastrointestinal symptoms

  • Food protein-induced enterocolitis syndrome (FPIES): these patients can present with emesis one to three hours after feeding, and constant exposure might result in abdominal distention, bloody diarrhea, anemia, and faltering weight and are provoked by cow’s milk or soy protein-based formulas.
  • Food protein-induced proctocolitis is known to cause blood-streaked stools in otherwise healthy infants in the first few months of life and is associated with breastfed infants.
  • Food protein-induced enteropathy is associated with steatorrhea and poor weight gain in the first several months of life.

Skin

  • Atopic dermatitis, also known as eczema, is linked to asthma and allergic rhinitis, and about 30% of children with moderate to severe atopic dermatitis have food allergies.
  • Acute urticaria and angioedema are one of the most common symptoms of food allergic reactions and tend to have very rapid onset after the responsible allergen is ingested. Most likely foods include egg, milk, peanuts, and nuts, but sesame and poppy seeds and fruits such as kiwi have been linked.
  • Perioral dermatitis is benign and is regularly a contact dermatitis caused by substances in toothpaste, gum, lipstick, or medications. These tend to resolve spontaneously.

Respiratory

  • Respiratory food allergies are uncommon as isolated symptoms. Wheezing occurs in approximately 25% of IgE-mediated food allergic reactions, but only approximately 10% of asthmatic patients have food-induced respiratory symptoms.

Evaluation

When suspecting a food allergy, the diagnostic approach begins with a careful medical history and physical examination. The history is particularly key in assessing a particular acute reaction such as systemic anaphylaxis, but also for attempting to establish which food was involved and what allergic mechanism is likely. A diet diary often can be helpful to supplement a medical history, especially in chronic disorders, as it identifies the specific food causing symptoms. A focused physical is also important, as an examination of the patient may provide signs consistent with an allergic reaction or disorder often associated with food allergy.[9][10]

When the history does not reveal the causative food allergen, allergy testing can be performed. For IgE-mediated disorders, skin prick tests (SPTs) provide a rapid means to detect sensitization to a specific food but has advantages and disadvantages as a positive test suggests the possibility of reactivity to a specific food, around 60% of positive tests do not reflect symptomatic food allergy. In contrast, a negative skin-prick establishes the absence of an IgE-mediated reaction. Therefore more definitive tests, such as quantitative IgE tests or food elimination and challenge, are often necessary to establish a diagnosis of food allergy.

Serum tests to determine food-specific IgE antibodies (e.g., RASTs) offer additional modality to assess IgE-mediated food allergy. Increasingly higher concentrations of food-specific IgE correlate with an increased likelihood of a clinical reaction. When a patient has a food-specific IgE level exceeding the predictive (diagnostic) values, he or she is more than 95% likely to experience an allergic reaction.

On the other hand, a provocative oral challenge is needed to establish whether a patient has hypersensitivity to a particular food, and the double-blind, placebo-controlled challenge is the gold standard for food allergy diagnosis. Suspect foods should be eliminated for 7 to 14 days before challenge, and longer in some non-IgE-mediated gastrointestinal disorders, to increase the likelihood of a non-equivocal food challenge result. Also, medications that could interfere with the evaluation of food-induced symptoms (e.g., antihistamines and b-adrenergic bronchodilators) must be discontinued. If symptoms remain unchanged despite appropriate elimination diets, it is unlikely that food allergy is accountable for the child’s disorder. If the blinded challenge result is negative, it must be confirmed using an open and supervised feeding of a typical serving of the food to rule out a false-negative challenge result that can occur in approximately 1% to 3% of the cases.

Treatment / Management

Once the diagnosis of food hypersensitivity is established, the only proven therapy remains elimination of the offending allergen, with the absence of a cure. Parents and children affected with food allergy require extensive education, including specific instruction on understanding food labels, restaurant meals, and risky behaviors leading to unexpected reactions. Patients at risk for anaphylaxis must be trained to recognize initial symptoms promptly and should be instructed on the proper use of auto-injectable epinephrine and have epinephrine and antihistamines accessible at all times.[11][12][13]

Patients with food allergy with asthma or a past history of severe reaction or reaction to peanuts, nuts, seeds, or seafood should be given self-injectable epinephrine and a written emergency plan for treatment of an unintentional ingestion. Clinical tolerance develops to most food allergens over time, except for peanuts, nuts, and seafood. Children with low levels of peanut-specific IgE should be reexamined to determine whether they have outgrown their allergy.

Prevention of Food Allergy

Currently, the recommendations are to introduce complementary solid foods, such as egg, peanut products, fish, wheat, and other allergenic foods one at a time after four to six months of age when breastfeeding, as there is no need to avoid or delay their introduction.

Differential Diagnosis

  • Factitious disorder
  • Esophagitis and esophageal motility disorders
  • Giardiasis
  • GERD
  • Irritable bowel syndrome
  • Bacterial or viral gastroenteritis
  • Lactose intolerance
  • Whipple disease

Complications

  • Anaphylaxis
  • Respiratory distress
  • Cardiac arrest

Consultations

  • Allergist
  • Pulmonologist
  • Pediatrician
  • Dietitian
  • Gastroenterologist

Pearls and Other Issues

Food allergic reactions are the most common cause of anaphylaxis seen in hospital emergency departments in the United States. Anaphylaxis is a potentially fatal allergic reaction that occurs rapidly and involves multiple systems including cutaneous, cardiovascular, respiratory, and gastrointestinal symptom.

Enhancing Healthcare Team Outcomes

Food allergies have become a problem in society. Even though the risk of anaphylaxis is rare, there is hysteria over certain foods in schools, hotels, and in many public places. The key is to educate the patient. All patients with a documented food allergy should be educated by the nurse to carry a self-injectable device that contains epinephrine. This device needs to be stored properly. The school nurse should provide the student with education on how and when to use the device. Older patients may be educated on the benefits of carrying an antihistamine in syrup or chewable form. More important, the pharmacist should educate the caregiver on how to use the epinephrine containing devices and how to identify an allergic reaction. The key is to avoid the allergen. A dietary consult is recommended so that the patient and the caregiver can be taught to identify food allergens and eliminate them from the diet. [2][14](Level V)

Outcomes

The majority of infants and young children develop tolerance to their food allergies with time. Most children outgrow their allergies to eggs, milk, and soy within 3-5 years. However, there are also reports that more than 50% of children will continue to have food allergies that persist to puberty. However, over time, even these children will develop tolerance to their allergies by the end of the second decade of life. Children who have non-IgE mediated food allergies such as enterocolitis usually have a cessation of their disorder within the first few years after birth.  Unfortunately, children with eosinophilic esophagitis may have symptoms that continue to persist. Severe anaphylactic reactions with food allergies are rare but do occur. The fatalities are usually seen in school children and the foods implicated include shellfish, peanuts, and fish. [15][16](Level V)


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    Contributed by Claudia Lopez, MD
Attributed To: Contributed by Claudia Lopez, MD

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Food Allergies - Questions

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Which of the following is not associated with childhood food allergies?



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Food allergies are mediated by which of the following types of immunoglobulin?



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Food Allergies - References

References

Loh W,Tang MLK, The Epidemiology of Food Allergy in the Global Context. International journal of environmental research and public health. 2018 Sep 18     [PubMed]
Dinakar C,Warady B, Food Allergy Care:     [PubMed]
Pham MN,Bunyavanich S, Prenatal Diet and the Development of Childhood Allergic Diseases: Food for Thought. Current allergy and asthma reports. 2018 Sep 18     [PubMed]
Budimir J,Mravak-Stipetić M,Bulat V,Ferček I,Japundžić I,Lugović-Mihić L, Allergic reactions in oral and perioral diseases-what do allergy skin test results show? Oral surgery, oral medicine, oral pathology and oral radiology. 2018 Aug 18     [PubMed]
Chang KL,Guarderas JC, Allergy Testing: Common Questions and Answers. American family physician. 2018 Jul 1     [PubMed]
Rial MJ,Sastre J, Food Allergies Caused by Allergenic Lipid Transfer Proteins: What Is behind the Geographic Restriction? Current allergy and asthma reports. 2018 Sep 11     [PubMed]
Shroba J,Rath N,Barnes C, Possible Role of Environmental Factors in the Development of Food Allergies. Clinical reviews in allergy     [PubMed]
Ramesh M,Karagic M, New modalities of allergen immunotherapy. Human vaccines     [PubMed]
Lacombe-Barrios J,Gómez F,Perez N,Barrionuevo E,Doña I,Fernández Tahia D,Mayorga C,Torres MJ,Moreno E,Gador B,Salas M, Accurate of the diagnosis of allergy reactions at the Emergency Department. Journal of investigational allergology     [PubMed]
Boudreau-Romano S,Qamar N, Peanut Allergy: Changes in Dogma and Past, Present, and Future Directions. Pediatric annals. 2018 Jul 1     [PubMed]
Deschildre A,Lejeune S, How to cope with food allergy symptoms? Current opinion in allergy and clinical immunology. 2018 Jun     [PubMed]
Muñoz VL, 'Everybody has to think - do I have any peanuts and nuts in my lunch?' School nurses, collective adherence, and children's food allergies. Sociology of health     [PubMed]
Pajno GB,Fernandez-Rivas M,Arasi S,Roberts G,Akdis CA,Alvaro-Lozano M,Beyer K,Bindslev-Jensen C,Burks W,Ebisawa M,Eigenmann P,Knol E,Nadeau KC,Poulsen LK,van Ree R,Santos AF,du Toit G,Dhami S,Nurmatov U,Boloh Y,Makela M,O'Mahony L,Papadopoulos N,Sackesen C,Agache I,Angier E,Halken S,Jutel M,Lau S,Pfaar O,Ryan D,Sturm G,Varga EM,van Wijk RG,Sheikh A,Muraro A, EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy. Allergy. 2018 Apr     [PubMed]
Oland AA,Booster GD,Bender BG, Integrated behavioral health care for management of stress in allergic diseases. Annals of allergy, asthma     [PubMed]
Al-Saud B,Sigurdardóttir ST, Early Introduction of Egg and the Development of Egg Allergy in Children: A Systematic Review and Meta-Analysis. International archives of allergy and immunology. 2018 Sep 5     [PubMed]
Yrjänä JMS,Koski T,Törölä H,Valkama M,Kulmala P, Very early introduction of semisolid foods in preterm infants does not increase food allergies or atopic dermatitis. Annals of allergy, asthma     [PubMed]

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