Contents

Search

food allergy

Etiology: 1) eating food allergens: most common (90% of food allergies) - eggs - milk - nuts, especially peanuts* - fish, especially shellfish - soybean - wheat 2) other - ~ 1.1 million people in the U.S. are allergic to sesame - cross-sensitivity between latex, banana, avocado, kiwifruit, chestnut, potato, green pepper & other fruits & nuts [14] - some food allergens may be heat-labile [12] * Children generally outgrow allergies to milk & eggs, but NOT to peanuts. Initial sensitization to peanuts may occur by touching peanuts. Most children with peanut allergies accidentally ingest peanuts [2] * skin contact with food allergen produces local reaction or none at all * proximity to someone consuming food allergen not a risk [23] Epidemiology: - self-reported food allergy more common than proven food allergy [14] - 11% of US adults have a food allergy, whereas ~ 19% of US adults believe that they have a food allergy [21] - food allergy is more common in children than adults - among children, food allergy is more common in those with other atopic diseases (atopic dermatitis, asthma, allergic rhinitis) - accidental food exposures frequently cause allergic reactions in preschool-aged children [7] - lower-income families have less access to support needed to prevent & treat food allergy complications, resulting in preventable emergency department visits & hospitalizations [17] Clinical manifestations: 1) IgE-mediated cutaneous reactions - acute urticaria (common), almost never chronic urticaria - flushing, pruritus - angioedema & anaphylaxis may occur 2) cell-mediated cutaneous reactions - contact dermatitis - dermatitis herpetiformis 3) mixed cutaneous reactions - atopic dermatitis 4) other - tingling, itching or metallic taste may occur while food is still in the mouth - within 15 minutes after swallowing the food, epigastric distress should occur - nausea/vomiting - lower abdominal cramping - diarrhea - wheezing Laboratory: - screening with serum IgE testing not indicated [12,14] - low levels of serum allergen (food)-specific IgE have low predictive value [23] - see ARUP consult [9] Special laboratory: 1) sensitive but non-specific testing a) skin testing for food allergens - skin prick testing - high sensitivity, moderate specificity - initial test of choice for food allergens [24] - intradermal skin testing - may result in false positives - may trigger severe reactions if food allergens are injected b) in vitro testing for specific IgE [4] c) reserve for patients with positive skin test or IgE but without convincing history [4] d) avoid food allergy panel testing e) check for allergies only to implicated foods f) focus on most common foods implicated in food allergies (see etiology) 2) double-blind food challenge test is the standard test a) end points are nausea/vomiting, diarrhea, abdominal cramps b) potentially dangerous test Management: 1) avoid offending food 2) epinephrine is 1st line treatment for all instances of anaphylaxis 3) antihistamines 4) glucocorticoids 5) patients with history of anaphylaxis to food should carry epinephrine kit (prescription for 2 doses) 6) activated charcoal may interfere with absorption of antihistamines & steroids [3] 7) anti-IgE therapy appears to confer protection against peanut reactions in some patients [4] 8) prevention - no medications or allergen-specific immunotherapies are recommended to prevent an allergic reaction [5,6] - for infants with a family history or atopy, consider partially or extensively hydrolyzed infant formula to prevent atopic dermatitis [14] - immunotherapy - omalizumab injections for 16 weeks, begun 8 weeks prior to oral immunotherapy with up to 5 allergens [10] - omalizumab FDA-approved for reducing allergic reactions to foods [10] - omalizumab increases threshold for reaction to peanuts & other common food allergens [25] - no evidence to support avoidance of foods with additives for chronic idiopathic urticaria [14] - not necessary to avoid all tree nuts in people with a single tree nut allergy [19] - introduction of allergenic foods at 3 months of age vs after 6 months of age in breast-fed infnats associated with lower prevalence of food allergy at 1-2 years of age (2.4 vs 7.3%) [16] - introducing infants to egg at ages 4-6 months & to peanut at ages 4-11 months is associated with reduced risk for egg allergy & peanut allergy

Related

angioneurotic edema; angioedema; atrophedema; Bannister's disease; Milton's disease; Quincke's disease; periodic or Quincke's edema; giant urticaria or hives; urticaria gigans, gigantea, or tuberosa. food poisoning (foodborne disease) insect sting or anaphylaxis kit (Ana-Kit) urticaria (hives)

Specific

cow's milk hypersensitivity (CMH); cow's milk allergy egg allergy multiple food allergies peanut allergy pollen-food allergy syndrome seafood allergy (include shellfish allergy)

General

type 1 hypersensitivity; immediate hypersensitivity (allergy) food intolerance

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 12, 27
  2. Journal Watch 21(3):24, 2001 Vander Leek J Pediatr 137:49, 2000
  3. Prescriber's Letter 10(8):45 2003
  4. Chafen JJ et al. Diagnosing and managing common food allergies: A systematic review. JAMA 2010 May 12; 303:1848. PMID: 20460624
  5. Boyce JA et al Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel J Allergy Clin Immunol 2020 226(6):s1 PMID: 21134576 http://download.journals.elsevierhealth.com/pdfs/journals/0091-6749/PIIS0091674910015666.pdf
  6. Fleischer DM et al. Oral food challenges in children in with a diagnosis of food allergy. J Pediatr 2011 Apr; 158:578.e1. PMID: 21030035
  7. Fleischer DM et al Allergic Reactions to Foods in Preschool-Aged Children in a Prospective Observational Food Allergy Study Pediatrics, June 25, 2012 http://pediatrics.aappublications.org/content/early/2012/06/20/peds.2011-1762.abstract
  8. National Institute of Allergy and Infectious Disease Guidelines for the Diagnosis and Management of Food Allergy in the United States corresponding NGC guideline withdrawn Jan 2016
  9. ARUP Consult: Food Allergies deprecated reference
  10. Begin P et al Phase 1 results of safety and tolerability in a rush oral immunotherapy protocol to multiple foods using Omalizumab. Allergy, Asthma & Clinical Immunology 2014, 10:7 PMID: 24576338 http://www.aacijournal.com/content/10/1/7 - Remaly J FDA Approves Drug to Reduce Accidental Food Allergies. Medscape. Feb 16, 2024 https://www.medscape.com/viewarticle/fda-approves-drug-reduce-accidental-food-allergies-2024a10003b3
  11. Centers for Disease Control and Prevention (CDC) Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs http://www.cdc.gov/healthyyouth/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf
  12. Lack G. Clinical practice. Food allergy. N Engl J Med. 2008;359(12):1252-1260. PMID: 18799559
  13. Choosing Wisely American Academy of Pediatrics Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/
  14. Sampson HA et al. Food allergy: A practice parameter update - 2014. J Allergy Clin Immunol 2014 Nov; 134:1016. PMID: 25174862 http://www.jacionline.org/article/S0091-6749%2814%2900672-1/abstract
  15. Bird JA et al. Food allergen panel testing often results in misdiagnosis of food allergy. J Pediatr 2014 Sep 10; PMID: 25217201
  16. Perkin MR, Logan K, Tseng A et al Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. N Engl J Med. March 4, 2016 PMID: 26943128 http://www.nejm.org/doi/full/10.1056/NEJMoa1514210 - Wong GW Preventing Food Allergy in Infancy - Early Consumption or Avoidance? N Engl J Med. March 4, 2016 PMID: 26943328 http://www.nejm.org/doi/full/10.1056/NEJMe1601412
  17. Bilaver LA, Kester KM, Smith BM, Gupta RS. Socioeconomic Disparities in the Economic Impact of Childhood Food Allergy Pediatrics May 2016 PMID: 27244806
  18. Ierodiakonou D et al Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune DiseaseA Systematic Review and Meta-analysis. JAMA. September 20, 2016 PMID: 27654604 http://jama.jamanetwork.com/article.aspx?articleid=2553447
  19. Couch C, Franxman T, Greenhawt M. Characteristics of tree nut challenges in tree nut allergic and tree nut sensitized individuals. Annals of Allergy, Asthma & Immunology. March 2017 PMID: 28359600 http://www.annallergy.org/article/S1081-1206(17)30112-6/abstract
  20. Jones SM, Burks AW Food Allergy N Engl J Med 2017; 377:1168-1176. September 21, 2017 PMID: 28930512 http://www.nejm.org/doi/full/10.1056/NEJMcp1611971
  21. Gupta RS, Warren CM, Smith BM et al Prevalence and Severity of Food Allergies Among US Adults. JAMA Netw Open. 2019;2(1):e185630 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720064
  22. Warren CM, Chadha AS, Sicherer SH et al Prevalence and Severity of Sesame Allergy in the United States. JAMA Netw Open. 2019;2(8):e199144. Aug 2. PMID: 31373655 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2740786 - Protudjer JLP, Abrams EM. Sesame: The New Priority Allergen? JAMA Netw Open. 2019 Aug 2;2(8):e199149. PMID: 31373645 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2740776
  23. NEJM Knowledge+ Allergy/Immunology
  24. Oriel RC, Wang J. Diagnosis and management of food allergy. Immunol Allergy Clin North Am. 2021;41:571-585. PMID: 34602229
  25. Wood RA et al Omalizumab for the Treatment of Multiple Food Allergies. N Engl J Med. 2024. Feb 24. PMID: 38407394 https://www.nejm.org/doi/full/10.1056/NEJMoa2312382
  26. National Institute of Allergy and Infectious Diseases (NIAID) Food Allergy https://www.niaid.nih.gov/diseases-conditions/food-allergy