Food Allergies & Anaphylaxis
3rd Annual South Florida Pediatric Nutrition
Symposium
Saturday August 12, 2017
Hanadys Ale, M.D.
Allergy and Immunology Fellow, PGY5
Learning Objectives
1. Understand the difference between food allergies versus adverse
reactions to foods
2. Review of the most common food allergens and specific food
allergens in common foods
3. Learn about the clinical course and natural history of some food
allergies
4. Review possible mechanisms of resolution/tolerance
5. Recognize the clinical manifestations of food allergies and
anaphylaxis and its treatment
6. Interpretation of tests for diagnosis of food allergies (ie skin prick
test vs ImmunoCap sIgE blood test)
7. Review of reasons for Allergy referral
Introduction
Food allergies or food intolerances affect nearly everyone at some
point.
People often have an unpleasant reaction to something they ate
and wonder if they have a food allergy.
Public perception of the prevalence of clinically proven food allergies
is significantly higher than the real prevalence.
This difference is in part due to reactions called "food intolerances"
or adverse reactions to food rather than true food allergies.
Prevalence of Food Allergy
Perception by public: 20-25%
Confirmed allergy:
› Adults: 3-4%
› Infants/young children: 5%
Prevalence higher in those with:
› Atopic dermatitis
› Pollen allergies
› Latex allergy
Prevalence increasing–18% increase between 1997-2007
Definition of Food Allergy
Abnormal immunologic response following exposure to a food that is
mediated by IgE molecules directed against specific food proteins that
activate mast cells and basophils, or can arise from other cellular processes
involving eosinophils or T cells.
Consequently, Food allergies are broadly categorized into either IgE-
mediated or non IgE-mediated processes.
Some disorders, such as atopic dermatitis or the eosinophilic gastrointestinal
disorders, have characteristics of both mechanisms.
Adverse Reactions to Food
A. Nonimmunologic
Toxic / Pharmacologic Non-Toxic / Intolerance
(no dependence of host factors) (dependence of host factors)
Bacterial food Lactase deficiency
poisoning Galactosemia
Heavy metal Pancreatic
poisoning
insufficiency
Scromboid fish
poisoning Gallbladder / liver
Caffeine disease
Alcohol Hiatal hernia
Histamine Gustatory rhinitis
Food Allergies
Immune Mediated
IgE-Mediated Non-IgE Mediated
B. Immunologic Spectrum
Anaphylaxis Eosinophilic Protein-Induced
Urticaria esophagitis Enterocolitis
Eosinophilic Protein-Induced
gastritis Enteropathy
Eosinophilic Eosinophilic
gastroenteritis proctitis
Atopic dermatitis
Pathophysiology: Allergens
Proteins (not fat / carbohydrate)
10-70 kD glycoproteins
Heat resistant, acid stable
Single food > many food allergens> Multiple Epitopes
(proteins)
Epitope: Areas of a protein to which the immune system
can respond
Conformational Epitopes
vs.
Linear Epitopes
Pathophysiology: Allergens
Most Common Food Allergens
Major allergenic foods (account for >85% of allergy)
Children: milk, egg, soy, wheat and as in adults
Adults: peanut, nuts, shellfish, fish
Mnemonic: WEMPS
• Wheat
• Eggs (Most common in atopic
dermatitis)
• Milk and Soy
• Peanuts and tree nuts
• Seafood (Crustacean and shellfish and fish)
Milk Allergy
• Most common food allergy in children, usually developing in the
first year
• Prevalence 2-3% of infants
• Milk proteins: casein (curds) and whey (soluble): lactalbumin,
lactoglobulin
• Many patients can tolerated baked milk, and chronic ingestion
may induce tolerance
Baked milk challengesfollowing a protocol and under
close observation at the Allergy Office or Hospital-based
set up (1st Fatality to food oral challenge reported recently)
• Mostly outgrown by 16 years . Median age: 10 years
Egg Allergy
• Second most common in children (Prevalence 1.3% )
• Egg white proteins: ovomucoid, ovalbumin, ovotransferrin, lysozyme
C, conalbumin
• Egg protein in influenza, yellow fever vaccines; (MMR no problem)
• As in milk allergy, many with egg allergy may
tolerate extensively heated (baked) foods containing
egg
• Mostly outgrown by adulthood. Median age in a
retrospective review of 881 patients with egg allergy
median age to develop tolerance was reported as 9
y/o
Peanut Allergy
Prevalence rising. It has more than tripled, from 0.4% in
1997 to 1.4% in 2008
Average age of presentation: 18 months
Although can present later in childhood or adulthood,
either as a primary food allergy or as part of the pollen-
food allergy syndrome.
75% reactions occur with first ingestion
› Environmental exposure important
The food allergy most commonly associated with
anaphylaxis
~20% peanut allergy resolution.
Natural History
Some IgE- mediated childhood food allergies, such as milk and egg
allergies, are more likely to resolve than others (peanut and tree
nuts).
Some studies suggest that resolution rates may have slowed
compared with impressions from past decades.
The ability to evaluate and predict the natural course of specific
food allergies for individual patients is essential to inform
personalized patient care
There are a number of clinical and laboratory factors associated with
the natural history of pediatric IgE- mediated food allergy
Factors Associated With The Natural
History of Food allergy
1. Clinical characteristics
Symptom severity on ingestion has been associated with the timing of resolution of allergy to
foods
Allergy persistence has been associated with more severe symptoms or lower threshold dose
required to elicit a reaction.
An earlier age at diagnosis and the presence of other comorbid allergic diseases are also
associated with a more persistent food allergy phenotype.
2. Allergic sensitization
Larger SPT wheal size or higher food-specific IgE levels are associated with persistent food
allergy.
The rate of change of food-specific IgE levels or SPT wheal size scan also help predict the
likelihood that a food allergy has resolved.
Mechanism of Resolution
Not fully understood
Likely that multiple mechanisms are involved.
Food-specific IgE levels tend to fall over time in most patients
and this loss of IgE is the best known predictor of the development
of clinical tolerance.
Some patients become tolerant even with persistently elevated
food-specific IgE levels.
Loss of IgE is not a requirement for the resolution of food allergy in
these patients.
Desensitization for Food Allergy
Trials ongoing with peanut, milk, egg
Oral, sublingual, transdermal forms
Researchers say it’s not ready for prime time
A few allergists are doing this
Consensus is avoidance, and Epi
Manifestations of food allergy
May develop hives, vomiting, diarrhea, swelling of
lips/tongue, wheezing, dizziness, respiratory
distress, LOC, hypotension (all systemic reactions)
Manifestations of food allergy
Any systemic reaction should be considered an
emergency
Most life-threatening are due to respiratory
distress, hypotension, or loss of consciousness
Reactions may be limited to scattered hives, and
upon the next exposure, difficulty breathing and
weakness may develop
Reactions can occur within minutes to two hours
after consumption
Anaphylaxis
Food-induced anaphylaxis
IgE mediated reaction
Rapid-onset
Multi-organ system involvement (2 or more systems)
Potentially fatal
Any food, but highest risk:
peanut, tree nut, seafood
Fatal Food Anaphylaxis
Frequency: over ~100 deaths / year
Individuals at higher Risk:
- Underlying asthma
- Symptom denial
- Teenagers
- Previous severe reaction
Fatal flaw: failure to promptly administer Epinephrine
Fatal reactions most commonly: Biphasic reaction
-initial mild symptoms within 30 minutes of ingesting the food that resolved recurrence of
severe symptoms 1-2 hours following the ingestion.
-important to observe patients with an acute anaphylactic reaction for at least 4 hours prior to
discharge from the emergency room.
Lack of cutaneous symptoms does not exclude anaphylaxis
Diagnosis: History / Physical
History: symptoms, timing, reproducibility
Acute reactions vs chronic disease
Diet details / symptom diary
Specific causal food(s)
“Hidden” ingredient(s)
Physical examination: evaluate disease severity
• Identify general mechanism
o Allergy vs intolerance
o IgE versus non-IgE mediated
Diagnosis: Laboratory Evaluation
Prick skin tests (SPT)
ImmunoCap sIgE (old term:RAST)
The test available for a routine use in the clinic can vary,
with some practices using mainly SPT, others mainly
sIgE and others both.
The future: Basophil Activation Test (BAT) Funtional
assay that uses live basophils in whole blood to
deterct the ability of IgE to mediate activation of
basophils after stimulation with allergen. (it goes
beyond detection of IgE binding to Allergen to detect
IgE fuction)
Devices for SPT
Interpretation of Laboratory
Tests
Positive prick test or RAST
Indicates presence of IgE antibody NOT clinical reactivity (high
false positive rate)
Negative prick test or RAST
Essentially excludes IgE mediated reactivity
Intradermal skin test with food
Risk of systemic reaction & not predictive
Contraindicated
Medications can alter the response to SPT
Prior to SPT it is important to take a detailed medication
history
Medications that suppress skin wheal
Anti-H1 histamines (Benadryl, Zyrtec, Allegra)
Anti-H2 histamines (Pepcid, Zantac)
Tricyclic Antidepressants (Doxepin)
Benzodiazepines (Clonazepam) Atypical Antidepressants (Olanzapine)
Recommendations to food allergic
patients
Avoidance, Avoidance, Avoidance
Keep food containing product out of the house
Tell family and friends about the food allergy, tell server
at restaurant
Aggressive food label reading!!
Refer to the Food Allergy Research and Education
(FARE) (800) 929-4040, www.foodallergy.org
Medic Alert Bracelet if anaphylaxis has occurred
Carry Epinephrine Autoinjector at all times –Epipen, AviQ,
Adrenaclikc, etc.
Treatment: Emergency
Medications
Epinephrine: drug of choice for reactions
Self-administered epinephrine readily available
Train patients: indications/technique
Antihistamines: secondary therapy
Emergency plan in writing
Schools, spouses, caregivers,
mature sibs / friends
Emergency identification bracelet
Treatment options
Epipen/ Auvi-Q:
Junior: Weight 15-30 kg 0.15 mg Epi
Regular: Weight above 30 kg 0.30 mg Epi
**Rx for Two-Pack**
Education is of utmost importance:
Indications for use
Proper administration
To ER or call 911 if ever used
- either accidentally or intentionally
***Debunk the myth that Benadryl will prevent progression of the reaction-
it will not!! Epi, Epi, Epi…!!***
Role of Allergist in food Allergy
Identification of causative food
Institution of elimination diet
Help in education
› Appropriate use of epinephrine
› Avoidance measure
Development of action plan
Prevention of other allergies
Determine when tolerance occurs
› When specific IgE drops to consider observed oral challenges
› Introduction of baked egg and milk
Removing “food allergy” label improves quality of life
References
Santos AF, et al. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):237-248.
Savage J, et al. J Allergy Clin Immunol Pract. 2016 Mar-Apr;4(2):196-203.
Sicherer SH, Sampson H. J Allergy Clin Immunol 2010;125:S116-125.
Skripak JM, Wood RA. Ped All Immunol 2008;19:368-73.
Ando H, et al, JACI, 2008;122:583-8.
Burks AW. Lancet 2008;371:1538-46.
Lemon-Mule H, et al. JACI 2008;122:977-83.
Bock SA, J Allergy Clin Immunol 2007;119:1016- 8.
Sicherer SH, Sampson HA. JACI 2007;120:491-503.
Skripak JM, et al. JACI 2007;120:1172-7.
Savage JH, et al. JACI 2007;120:1413-7.
Joint Task Force on Practice Parameters: AAAAI, ACAAI, and JCAAI. J Allergy Clin Immunol 2005;115:S483-523.
Thank you!!!!
Questions??
