Download Food Allergies: Not Just Peanuts, Eggs, and Milk

2/12/2016
Food Allergies:
Not Just Peanuts, Eggs, and Milk
Disclaimers
Karleen McGill MS, BC-FNP
• Dr. Karen Rance authored this slidedeck
Objectives
• I have no financial disclosures.
Food Allergy Definition
• Identify an evidence-based approach to managing food
allergy patients with both common and less common
allergens
• Discuss how to screen for possible sensitivity to food
additives and preservatives
• Describe a management approach for patients with multiple
food allergies
 An immunological response to primarily a food protein
whose reactions can be severe or life-threatening.
 An immune-mediated adverse food reaction.
• Food allergy is the most common cause of anaphylaxis
either inside or outside of the Emergency Department.
• Must be differentiated from food intolerances and other
adverse food reactions
Burks, A., Tang, M., Sicherer, S., Muraro, A., Eigenmann, P. A., Ebisawa, M., ... & Sampson, H. A. (2012). ICON: food allergy. Journal of Allergy and Clinical Immunology, 129(4), 906-920.
Food Allergy (FA) Prevalence is Increasing
Types of Adverse Food Reactions
• Self-reported prevalence of FA is 8.96%: children = 6.53% and adults =
9.72%
Toxic
Nontoxic
• Estimated that 2 children in every classroom of 25 children have FA
• Children with FA are more likely to have asthma or other allergic
conditions than those without FA
Food Allergy
IgE
Mixed (IgE/non-IgE)
Food Intolerance
Metabolic
Pharmacologic
• In the last 10 years, food-induced anaphylaxis hospitalizations has
increased more than 3-fold.
• 170 foods have been identified as causing an IgE-mediated response
Idiosyncratic
Adapted; Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008
American Academy of Allergy, Asthma, and Immunology. (2013). Updated prevalence of food allergy in the United States. Retrieved from http://www.aaaai.org/global/latest-research-summ aries/Current-JACI-R esearch/food -allergy-inus.aspx
Boyce, J. A., Assa'ad, A., Burks, A. W., Jones, S. M., Sampson, H. A., Wood, R. A., ... & Schwaninger, J. M. (2010). Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert
panel. The Journal of allergy and clinical immunology, 126(6 Suppl), S1.
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8 Foods Cause 90% of IgE-Mediated Food Allergy
Natural History
Exposure
Genetic Predisposition
Sensitization
Re-exposure
Symptoms
Burks, A., Tang, M., Sicherer, S., Muraro, A., Eigenmann, P. A., Ebisawa, M., ... & Sampson, H. A. (2012). ICON: food allergy. Journal of Allergy and Clinical Immunology, 129(4), 906-920.
The Natural History of Peanut Allergy
The Natural History of Egg Allergy
• Peanut allergy affects 1% of children
• Medical records of 581 pts reviewed at
pediatric allergy clinic for those
outgrowing egg allergy
– By age 4
4%
– By age 6
12%
• There is a strong association between
higher IgE levels and reaction severity.
• The annual incidence rate of
accidental exposure for children with
peanut allergy is 12.5%.
• Children and adolescents are at higher
risk.
Nguyen‐Luu, N. U., Ben‐Shoshan, M., Alizadehfar, R., Joseph, L., Harada, L., Allen, M., ... & Clarke, A. (2012). Inadvertent exposures in children with peanut allergy. Pediatric Allergy and Immunology, 23(2), 134-140.
Neuman-Sunshine, D. L., Eckman, J. A., Keet, C. A., Matsui, E. C., Peng, R. D., Lenehan, P. J., & Wood, R. A. (2012). The natural history of persistent peanut allergy. Annals of Allergy, Asthma & Immunology, 108(5), 326-331.
• Baseline milk-specific IgE
level, SPT wheal size, and AD
severity were important
predictors of the likelihood of
resolution.
Wood, R. A., Sicherer, S. H., Vickery, B. P., Jones, S. M., Liu, A. H., Fleischer, D. M., ... & Sampson, H. A. (2012). The natural history of milk allergy in an observational cohort. Journal of Allergy and Clinical Immunology.
37%
68%
– By age 18
80%
Savage, J. H., Matsui, E. C., Skripak, J. M., & Wood, R. A. (2007). The natural history of egg allergy. Journal of Allergy and Clinical Immunology, 120(6), 1413-1417.
Determining Severity of Reactions
The Natural History of Milk Allergy
• Research: in cohort of infants
(#293) with milk allergy, 50%
resolved over 66 months of
follow up.
– By age 10
– By age 16
–
–
–
–
–
–
–
Significant Contributors:
Near Fatal Reactions with:
Amount ingested
Raw vs. cooked
Co-ingestion of other foods
Age
Degree of sensitization
Empty stomach
Exercise
• Comorbidity of asthma –
especially severe, on chronic
corticosteroids
• Delayed use of epinephrine with
reliance on Benadryl
• Alcohol consumption –
increases food absorption
Boyce, J. A., Assa'ad, A., Burks, A. W., Jones, S. M., Sampson, H. A., Wood, R. A., ... & Schwaninger, J. M. (2010). Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert
panel. The Journal of allergy and clinical immunology, 126(6 Suppl), S1.
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Evidence-based Approach
• NIAID Food Allergy Guidelines:
Guidelines for the Management
and Diagnosis of Food Allergy in
the United States
http://www.niaid.nih.gov/topics
/foodallergy/clinical/Pages/defa
ult.aspx.
Evidence Based Approach
• Joint Task Force on Practice
Parameters: Food Allergy: A
Practice Parameter Update-2014
Available at www.AAAAI.org
Diagnostic Evaluation of Food Allergy
Prick Skin Testing: Is it Life-threatening?
Diagnostic Approach to the Evaluation of Food Allergy
• Sporik et al study in 3 yr olds (large cohort) prick testing & food challenges to
determine parameter of “life threatening risk”:
Detailed History and Physical
Combined
IgE-mediated
SPT/ssIgE
– Peanut > 8mm over control
Non-Ige-mediated
– Cow’s milk > 8 mm over control
– Egg > 7 mm over control
GI Consultations/Endoscopy
• Studies have demonstrated that the wheal size and specific IgE level can be
associated with the severity of reactions on oral challenge.
-
-
Elimination Diet
Reconsider
Reconsider
Reconsider
• Negative predictive accuracy of a properly performed prick test exceeds 95%
Food Challenge
-
Specific Allergen=Elimination Diet
Reconsider
Adapted from Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update;Vol. 24 #2; Summer 2008
Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008
Lieberman, J. A., & Sicherer, S. H. (2011). Diagnosis of food allergy: epicutaneousskin tests, in vitro tests, and oral food challenge. Current allergy and asthma reports, 11(1), 58-64.
Testing
Lab Testing
• There is no consensus on the
comparability of skin testing and
selected ssIgE testing.
• However, prior to a food challenge in
a patient with a highly suggestive
history and a negative in vitro test,
prick skin testing is advised
• Skin prick testing options—systemic symptoms are rare
– Glycerinated
– Fresh food extracts
– Prick-prick test
• Positive predictive accuracy < 40% if 3mm greater than
control criteria is used
• Peanut protein component testing available to determine
risk level for oral challenge: Ara h2 and Ara h8 are best
predictors.
Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008
Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008
Johnson K & Daitch L. (2011). Peanut Allergy Awareness. Clinician Reviews; Vol 21(12).
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Cross Reactivity and Food Allergen Groups
• When an allergic response is established toward a particular
protein, presentation of a homologous form of that protein
in another substance may also trigger an allergic response.
• Allergic reaction to multiple foods may follow initial
sensitization caused by 1 food or nonfood allergen such as
pollen.
Related Diagnoses
• Food allergens are derived from just a few protein families.
• Over 70% identity in primary sequence is needed for crossreactivity.
Sicherer, S. H. (2013). 25 Hidden and Cross-Reacting Food Allergens. Food Allergy: Adverse Reaction to Foods and Food Additives.
Cross Reactivity: Clinical Application
• Decisions to avoid foods as a group currently are based upon
concerns about cross-contact or misidentification of the
allergens. Studies are lacking showing evidence of challenge
results.
• Decisions can be individualized based upon clinical
judgment, patient preference, nutritional considerations,
and availability of safe foods.
Sicherer SH; Clinical implications of crossreactive food allergens’ JACI; 2001;108 885
Oral Allergy Syndrome
• Reactions occur because the proteins found in some fruits and vegetables are
very similar to those found in pollen. These proteins can confuse the immune
system and cause an allergic reaction or make existing symptoms worse.
• Cross-reactivity happens when the immune system thinks one protein is
closely related to another.
• Most frequent reactions involve itchiness or swelling of the mouth face, lip
tongue and throat.
• Individuals react to different foods based on what type of seasonal allergies
they are affected by.
• If a patient develops a pollen allergy prior to developing OAS, the reactions
are less likely to be life threatening.
Webber, C. M., & England, R. W. (2010). Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Annals of Allergy, Asthma & Immunology, 104(2), 101-108.
Sicherer, S. H. (2013). 25 Hidden and Cross-Reacting Food Allergens. Food Allergy: Adverse Reaction to Foods and Food Additives.
Eosinophilic Esophagitis
• Studies show complete food elimination as EoE’s most
effective treatment
• However, the drawbacks of an elemental diet have led to
use of a 6-food elimination diet and skin prick
test/atopy patch test-directed diet. Studies show that
SPT may lead to better results.
• Spergel et al reported that 77% of 319 patients with EoE
responded to diet modifications guided by SPT/APT
plus empiric milk elimination compared with 53% of
those on SPT/APT-based elimination alone.
• Fresh food SPT has been shown to identify food
sensitivities not detected with commercial extracts
Liacouras, C. A., Furuta, G. T., Hirano, I., Atkins, D., Attwood, S. E., Bonis, P. A., ... & Aceves, S. S. (2011). Eosinophilic esophagitis: updated consensus recommendations for children and adults. Journal of Allergy and Clinical Immunology, 128(1),
3-20.
Holbreich, M. (2008). A comparison of fresh vs commercial extracts for food testing. Journal of Allergy and Clinical Immunology, 121(2), S251.
Spergel, J. M., Brown-Whitehorn, T. F., Cianferoni, A., Shuker, M., Wang, M. L., Verma, R., & Liacouras, C. A. (2012). Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. Journal of Allergy
and Clinical Immunology.
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Irritable Bowel Syndrome-Diarrhea Predominant
• In patients with AR, FA, or history of atopic disease,
the odds of IBS-D are 12.0, 6.96, and 4.2, respectively,
compared with those who do not have these
symptoms.
• Study: 100 patients who had undergone endoscopies
and biopsies with immunostaining for mast cell
tryptase were selected from the pathology
department’s database.
• In comparison to patients with intestinal mast cell
counts less than 15, patients with 15-19 mast cells/hpf
have twice the probability of having IBS-D when
controlling for atopic status.
• In patients with >19 mast cells/hpf, the presence of
atopic disease quadrupled the odds of IBS-D.
Mittel, R. J., Demeo, M., Jakate, S., Mikolaitis, S., Tilmon, S., & Tobin, M. C. (2013). The Relationship Between Atopic Disease, Mast Cell Counts and Irritable Bowel Syndrome-Diarrhea Predominant (IBS-D). Journal of Allergy and
Clinical Immunology, 131(2), AB178-AB178.
Alpha-Gal Allergy
Patch Testing and IBS-D
• Patch testing may be useful in identifying the causative
foods.
• Study: OBJECTIVE - skin patch testing to common allergenic
foods and food additives on individuals with a history of or
symptoms suggestive of IBS-D. Patch test–guided avoidance
diets were used to determine whether avoidance alleviates
IBS-D symptoms.
• Results: 30 of the 51 study participants showed at least 1
positive patch test result. Fourteen of the participants
reported symptomatic improvement, ranging from slight to
great, upon avoidance of the foods/food additives to which
they reacted.
Stierstorfer, M. B., Sha, C. T., & Sasson, M. (2012). Food patch testing for irritable bowel syndrome. Journal of the American Academy of Dermatology.
Allergic Reactions to Food Additives
• Recent studies have linked the consumption of meat to an alpha-gal
allergy causing a reaction to red meat, which occurs after being bitten by
a tick and may lead to anaphylaxis.
• Food additives basic functions: make food safer by
preserving it from bacteria and preventing oxidation
• The link is a sugar, commonly called alpha-gal, found in the meat of all
non-primate mammals, including cows, pigs, sheep and goats.
• Food additives are potential hidden allergens as everyone is
exposed to them every day
• Drs. Platts-Mills and Cummins at the University of Virginia found that a
tick bite (specifically the lone star tick, which is indigenous in the
southeastern United States) is a cause, possibly the sole cause, of IgE
production related to alpha-gal.
• The tick bite introduces alpha-gal into the skin of an individual, causing
the creation of specific IgE in some people.
• Among sensitive subjects, potential of allergic reaction to
food additives is reported as 0.03-.23%
• Some food additives may cause an allergic reaction by
inhalation or by topical administration, but not just by
ingestion
• If not exposed again through another tick bite, the allergy usually
resolves within eight months to three years.
Platts-Mills, T. A., & Commins, S. P. (2013). Emerging antigens involved in allergic responses. Current opinion in immunology, 25(6), 769-774.
Gultekin, F., & Doguc, D. K. (2012). Allergic and Immunologic Reactions to Food Additives. Clinical reviews in allergy & immunology, 1-24.
Food Additive Groups Known to Cause Reactions
Testing for Allergy to Food Additives
• Antioxidants (such as BHA and BHT)
• Patients with adverse reaction to food additives should be evaluated
for sensitivity to annatto (yellow) and carmine (red) as they have been
linked to anaphylaxis.
• Colors (food dyes)
• Emulsifies and stabilizers (such as gums and lecithin)
• Solvent
• Glazing agents (such as stearic acid, beeswax, lanolin, esters)
• Preservatives (such as benzoates, nitrates, and sulfites)
• There is also evidence that guar gum, psyllium, carrageenan, arabic,
xanthum, pectin, gelatin, mycoprotein, and certain spices have caused
anaphylaxis.
• Natural food additives and spices should be included in the work-up
of patients with a history of unexplained anaphylaxis.
• Flavoring and sweetening agents
• Thickeners
Degaetani, M. A., & Crowe, S. E. (2010). A 41-Year-Old Woman With Abdominal Complaints: Is It Food Allergy or Food Intolerance? How to Tell the Difference. Clinical Gastroenterology and Hepatology, 8(9), 755-759.
Nish, W., Whisman, B., Goetz, D., & Ramirez, D. (1991). Anaphylaxis to annatto dye: a case report. Annals of Allergy, Asthma, and Immunology, 66(2):129‐31.
Beaudouin, E., Kanny, G., Lambert, H., Fremont, S., & Moneret‐Vautrin, D.(1995). Food anaphylaxis following ingestion of carmine. Annals of Allergy, Asthma & Immunology, 74(5):427‐30
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Case Study: C. Gum
Case Study: continued
• 39 year old female
• Working diagnosis: angioedema – suspect something ingested
• History of random and unanticipated tongue and throat
swelling for 4 weeks, 3 episodes.
• Lab work ordered: ANA, liver enzymes, BUN, creatine, C4, ESR,
total IgE level, UA, vitamin D level, thyroid studies, ssIgE levels
for foods and food additives
• Initial episode - ate cream pie (store bought) and developed
swelling within 3 minutes.
• All lab work negative, except for Carrageenan Gum (+)
• No hives or rash
• History of IBS-C
• Implemented avoidance diet of C. Gum
• At 3 month f/u: no incidences of angioedema on C. Gum
avoidance diet. Patient also reported decreased IBS-C symptoms
on avoidance diet.
• Patient declined re-challenge.
Dust Mites and Food Allergy
• House dust mites and storage
mites are commonly found in
grain, fishmeal, and dried fruit.
• Dust mite sensitive patients may
react to a food that has been in
extended storage and exposed to
dust mites.
Cui, Y. (2013). Immunoglobulin E-Binding Epitopes of Mite Allergens: From Characterization to Immunotherapy. Clinical reviews in allergy & immunology, 1-10.
CASE STUDY Results
• The patient underwent SLIT extract for mites without any adverse
events. The maintenance dose, regularly achieved, was 5 drops a day
for 12 months, that is twice the recommended dose. This was done to
achieve a high enough cumulative dose of tropomyosin, that was 146
µg.
• After 12 months the symptom/medication score decreased by
approximately 40% and drug intake for asthma and rhinitis also
decreased by 40%. At 12 months an oral challenge with a single
shrimp was done, and it caused only an oral allergic syndrome,
without systemic symptoms. In addition, the patient accidentally ate
shrimps in small quantities at home, without any symptoms.
Experimental Approach:
Dust Mite Allergy and Shrimp Allergy
• The presence of allergy to shrimp is currently a
hypothetical contraindication to specific
immunotherapy for house dust mites.
• CASE STUDY: A 15 year-old male presented with mild
persistent asthma and rhinitis due to mites, and
concomitant allergy to shrimps and seafood, with
anaphylactic symptoms: urticaria, glottis edema,
asthma, enteritis.
Cortellini, G., Spadolini, I., & Santucci, A. (2011). Improvement of shrimp allergy after sublingual immunotherapy for house dust mites: a case report. European annals of allergy and clinical immunology, 43(5), 162-164.
Food Induced Allergic Rhinitis
• The prevalence of food-induced allergic rhinitis
appears to be less than 1 percent.
• Food reactions often lead to rhinitis symptoms
without an immunologic nature.
• Although the role of food and fruits in developing
allergic rhinitis is not clearly identified, in a very
small percentage of patients, rhinitis is among the
clinical manifestations of food allergy.
Bemanian, M. H., Arshi, S., & Nabavi, M. (2013). Food-induced Allergic Rhinitis. Journal of Pediatrics Review, 1(1), 53-55.
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Celiac Disease
• Celiac disease (CD) is a chronic small intestine immunemediated condition triggered by exposure to gluten in genetically
sensitive individuals (DQ2+ or DQ8+).
• Gluten is a protein component found in wheat, barley, and rye
(but not in oats).
• The gluten-free diet is currently the only available treatment for
CD, although ongoing pharmacological and vaccine trials
promise future alternatives.
FPIES
• Food protein-induced enterocolitis syndrome (FPIES) is a non–IgEmediated gastrointestinal food hypersensitivity that manifests as
profuse, repetitive vomiting, often with diarrhea, leading to acute
dehydration and lethargy or weight loss and failure to thrive if
chronic.
• FPIES is elicited most commonly by milk and soy proteins; however,
rice, oat, and other solid foods may also elicit FPIES.
• Certain FPIES features overlap with food protein-induced enteropathy
and proctocolitis, whereas others overlap with anaphylaxis.
• Usually ST are negative for milk and soy.
Ludvigsson, J. F., Biagi, F., & Corazza, G. R. (2014). Epidemiology of Celiac Disease. In Celiac Disease (pp. 27-37). Springer New York.
Järvinen, K. M., & Nowak-Węgrzyn, A. (2013). Food Protein-Induced Enterocolitis Syndrome (FPIES): Current Management Strategies and Review of the Literature. The Journal of Allergy and Clinical Immunology: In Practice.
Role of Diet in Nickel Allergy
• Nickel is a ubiquitous trace element and the
commonest cause of metal allergy among people.
Skin Conditions Associated
with Food Allergy
• Nickel allergy is a chronic, recurring problem; females
are affected more commonly than males. Nickel
allergy may develop at any age. Once developed, it
tends to persist life-long.
• Nickel in the diet of a nickel-sensitive person can
provoke dermatitis. Careful selection of foods with
relatively low nickel concentrations can bring a
reduction in the total dietary intake of nickel per day.
Sharma, A. D. (2013). Low nickel diet in dermatology. Indian journal of dermatology, 58(3), 240
Low Nickel Diet
Foods that Contain Nickel
• Nickel is present in most of the dietary
items and food is considered to be a major
source of nickel.
• High content (> 0.5mg/kg): almond, asparagus, beans,
buckwheat, chickpeas, cocoa powder, dark chocolate, fresh
pears, hazelnut, herring, linseed, mussels, oat bran,
oatmeal, onions, peanut, pistachio nuts, poppy seed, soy
beans, soy flour, walnuts, wheat bran, yellow peas.
• Nickel when administered orally (600-5600
mg) as a single dose provoked hand
eczema.
• Evidence cites improvement of dermatitis
on a low nickel diet.
• Common sources of nickel foods: cereals,
fish, canned vegetables, nuts, instant tea
and coffee, dried peas.
Sharma, A. D. (2013). Low nickel diet in dermatology. Indian journal of dermatology, 58(3), 240.
• Medium content (0.1-0.5 mg/kg): barley, black current,
corn flour, eggs, garlic, horseradish, kale, milk chocolate,
oysters, parsley, parsnip, raspberries, rice, rye, various
mushrooms, yeast.
Adams Allergy: Parveneh Abadee, M.D. / Denis J. Yoshii, D.O., 1700 Adams Ave #100, Costa Mesa, CA 92626
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Balsam of Peru Diet
Food-Dependent Exercise Induced Anaphylaxis
• Balsam of Peru, composed of a variety of components, is a
fragrance found in foods such as alcohol, citrus fruits,
chocolate, pickle vegetables, spices, and tomatoes that has
been associated with systemic contact dermatitis.
• FDEIA is a distinct condition in which anaphylaxis develops only if
physical activity occurs within a few hours after eating a specific food.
This disorder has been reported with a wide variety of foods.
• The diagnosis can be made by history and atopy patch
testing but also may require dietary elimination or food
challenge of the suspicious food or food components.
• The foods most commonly implicated in food-dependent exerciseinduced anaphylaxis include wheat, shellfish, tomatoes, celery, peanuts,
and corn.
• Balsam of Peru is a well-known contact allergen that is one
of the most prevalent in the United States. For some
patients allergic to BOP, external avoidance of fragrance is
not enough to eliminate their dermatitis.
Scheman, A., Rakowski, E. M., Chou, V., Chhatriwala, A., Ross, J., & Jacob, S. E. (2012). Balsam of peru: past and future. Dermatitis: contact, atopic, occupational, drug: official journal of the American Contact Dermatitis Society, North American
Contact Dermatitis Group, 24(4), 153-160.
Image: http//www.the-dermatologist.com
Romano A, Di Fonso M, Giuffreda F, et al. (2001). Food-dependent exercise-induced anaphylaxis: clinical and laboratory findings in 54 subjects. Intl Archives All Imm. 125(3):264-72.
Food Processing and Allergenicity
• The alteration of allergenicity of a protein during the manufacturing
process may determine how provoking the food is.
Management of Food Allergies
• The heating process of baking destroys the protein structure to
which the patient is sensitive.
• For example, some egg sensitive children may be able to tolerate
eggs in baked products, but not when eaten alone.
Sicherer, S. H., & Sampson, H. A. (2010). Food allergy. Journal of Allergy and Clinical Immunology, 125(2), S116-S125.
Allergenicity
For many patients, fruits and vegetables cause
allergic reaction primarily if eaten raw, but
may still cause reactions after being
thoroughly cooked or having undergone
digestion in the stomach and intestines.
Allergenicity of Oils
• Oils are commonly derived from soy, corn, peanut, and sesame.
• They may range in their allergenicity depending on how much of the
food protein is removed in process.
• Consuming highly refined oils developed from major allergenic food
sources does NOT appear to be associated with allergic response.
Sicherer, S. H., & Sampson, H. A. (2010). Food allergy. Journal of Allergy and Clinical Immunology, 125(2), S116-S125.
Food Allergy Research Education. Available at http://www.foodallergy.org
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Cross Contact Through Saliva
Cold Pressed vs. Cooked Oils?
• According to the FARE, “Studies show that most allergic individuals can safely eat
peanut oil (not cold pressed, expelled, or extruded peanut oil - sometimes
represented as gourmet oils).”
• Cold pressed oils are obtained trough pressing and grinding fruit or seeds with the
use of heavy granite millstones or modern stainless steel presses
•
The temperature must not rise above 120°F (49°C) for any oil to be considered cold
pressed.
• Cold pressed oils retain all of their f lavor, aroma, and nutritional value - olive,
peanut and sunf lower are among the oils that are obtained through cold pressing
• Cold pressed oils are considered more risky for patients to consume due to their
retention of more allergenic proteins.
Food Allergy Research Education. Available at http://foodallergy.org
• Allergic reactions are possible via saliva exchange, including
risks associate with sharing straws, cups and utensils.
• Discuss appropriateness of “peanut-free table” in school
setting with patients.
• “Allergic Kiss of Death” is NOT a myth.
• The safest strategy is that the family of the food allergic child
also avoid the allergenic food.
Maloney, J. M., Chapman, M. D., & Sicherer, S. H. (2006). Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. Journal of allergy and clinical immunology, 118(3), 719-724.
Food Product Label
• Manufacturers must detail allergen information
for top 8 food allergens (milk, eggs,
fish/crustaceous fish, peanuts, tree nuts, wheat,
and soy).
• Manufacturers must list the specific nut (e.g.,
almond, walnut, cashew) or seafood (e.g., tuna,
salmon, shrimp, lobster) that is used in the
product.
Are Patients Reading Food Labels?
• No.
• Studies demonstrate increasing numbers of FA
consumers are NOT reading precautionary labeling and
instead choose to ingest products. Reasons include:
– They state recognition of increase warnings and therefore do
not rely on labels due to being overwhelmed and not knowing
what to trust.
– FA consumers state they don’t have a reaction after ingestion
and so don’t need to follow warnings .
– FA consumers state that advisory labeling is used for legal
reasons only.
Food and Drug Administration (FDA). (2013). Food allergen labeling and consumer protection act of 2004. FDA website.
Are Precautionary Labels Accurate?
• Not always. Current labeling laws relate only to intentionally added ingredients.
• Consumers must make risk assessments based on precautionary labeling.
• Products with precautionary labeling, such as “this product may contain trace amounts of
allergen” should be avoided.
• In a sample of 401 foods, 5.3% of products with advisory labels had detectable protein, where as
1.9% of the products with no warnings were contaminated.
Hefle, et al.(2007). Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. Journal of Allergy Clinical Immunology, 120, 171-176.
Follow Up
• Allergies to milk, egg, wheat, soy generally resolve more
quickly in childhood than peanut, tree nuts, fish and
shellfish.
• Consider the natural course of allergies to specific foods
when deciding upon frequency of food allergy follow-up
evaluations
“When in doubt, don’t eat it!”
Hefle, et al.(2007). Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J All Clin Imm, 120, 171-176.
Sicherer, S. & Sampson, H. (2014). Food allergy: epidemiology, pathogenesis, diagnosis, and treatment. JACI, 133, 291-307.
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The Future
Research continues on in-utero and breast milk sensitivity
and sustained oral sensitization over time.
No current immunotherapy available for FA desensitization.
….And the beat goes on!
Thank You!
[email protected]
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