Download Food Allergies in the trenches Dan Atkins, MD

Colorado Chapter Meeting
American Academy of Pediatrics
May 8, 2015
Food Allergy in the Trenches
Dan Atkins, MD
Chief, Allergy Section
Co-Director, Gastrointestinal Eosinophilic Diseases Program
Children’s Hospital Colorado
Associate Professor of Pediatrics
University of Colorado School of Medicine
!
Disclosures
•  APFED: Medical Advisory Panel member
•  DBV Technologies: Consultant, member of Data
Safety Monitoring Board for the study entitled:
“A DBPC Randomized Trial to Study the Viaskin
Milk Efficacy and Safety for Treating IgEmediated Cow’s Milk Allergy in Children”
•  Regeneron: Consultant, single episode
Learning Objectives
1.  Distinguish IgE from non-IgE mediated food allergies
and illustrate how each type commonly presents to
the PCP’s office.
2.  Develop a practical approach to the evaluation and
management of a child brought for a suspected IgEmediated food allergy including important
components of the history, typical clinical
presentations, the role of skin testing and serum
food specific IgE testing, counseling points and
when to refer to an allergist.
3.  Educate parents about prevention strategies
regarding the introduction of solid foods.
1
Resource References
1.  Sicherer SH & Sampson HA. Food Allergy:
Epidemiology, pathogenesis, diagnosis and
treatment. J Allergy Clin Immunol 2014;133:291-307.
2.  Bird, JA, et al. Clinical management of food allergy. J
Allergy Clin Immunol Pract 2015;3:1-11.
3.  Sampson HA, et al. Food allergy: A practice
parameter update 2014. J Allergy Clin Immunol
2014;134:116-125.
4.  Caubet JC, et al. Clinical features and resolution of
food protein-induced enterocolitis syndrome: 10
year experience. J Allergy Clin Immunol 2014;
134:382-9.
COMMON QUESTIONS
•  Is my child allergic to (specific
food) or will my child have a
reaction if she/he eats (specific
food)?
??
? ?
•  Will the next reaction to the food
be similar to previous reactions,
less severe or worse?
•  Could (will) my child die from an
allergic reaction to the food?
Oatmeal Studios
•  Will or has my child outgrown
her/his allergy to the food?
ADVERSE FOOD REACTION
IMMUNE MEDIATED
(FOOD ALLERGY)
- IgE
- Non-IgE
- Mixed IgE & non IgE
- Cell Mediated
NON-IMMUNE MEDIATED
(FOOD INTOLERANCE)
- Toxic
- Metabolic
- Pharmacologic
- Idiosyncratic
- Other
J ALLERGY CLIN IMMUNOL 2010:126:S1-S58
2
SUSPECTED FOODS
•  Route of exposure
–  Ingestion
Contact
Inhalation
Inhalation reactions:
Peanut dust- possible
Peanut butter- doubtful
Injection
•  Amount ingested
–  Minute
Small
Medium
Large
•  Manner of preparation
–  Raw
–  Plain
Cooked
Spices
Both
Mixed with other foods
Which dye is capable of causing
IgE-mediated reactions?
Preservatives
Dyes
•  Simultaneously ingested foods
–  None
Few
Multiple
•  Illness in others ingesting the same food
In which condition will skin testing
yourself to a fresh extract of the
offending food make the diagnosis?
•  Review of current diet
–  Which of the simultaneously ingested foods have been eaten again without
reaction?
–  Patients are sometimes eating the food to which they think they are allergic
as an ingredient in another food.
DESCRIPTION OF REACTIONS
•  Timing of onset in
relation to food ingestion
•  Symptoms
•  Severity
•  Duration of reaction
•  Treatment of reaction
•  Reproducibility of
reaction after ingestion
of suspected food
•  Most recent reaction
Duration of Reactions
•  Dose, emesis, treatment
•  Mild to moderate reactions are usually hours long
•  Biphasic reactions are rare, but concerning
•  Prolonged reactions are extremely rare
•  Hives lasting for days are rarely food-driven
without other evidence to suggest food as
the cause
Reasons for lack of reproducibility
•  Not IgE-mediated food allergy
•  Focused on wrong food as cause
•  Cross contamination with another food
•  Food allergen denatured by cooking
•  Added spice rather than the food
•  Need another trigger such as exercise
FOOD ALLERGY: DIAGNOSTIC TOOLBOX
HISTORY
LABORATORY
Skin testing:
Commercial
and/or
Fresh extracts
PHYSICAL
EXAM
PROCEDURES
CONSULTATIONS
Allergist
Food Challenges
Ingestion
Dietician
Inhalation
Contact
Gastroenterologist
Elimination diet
ImmunoCAP
Patch testing
Other
Impedance/pH
probe
Feeding therapist
Endoscopy
Psychosocial
Clinician
Other
Other
3
DIAGNOSTIC APPROACH TO THE EVALUATION OF FOOD ALLERGY
Detailed History
+
Non-IgE-mediated
Food Protein Induced Enterocolitis Syndrome (FPIES)
•  Irritability, vomiting and diarrhea
•  Occult blood in stool
Endoscopy
+
-
Food Protein Induced Enteropathy
•  Diarrhea, failure to thrive, abdominal distention, early
satiety, malabsorption
•  Less frequent anemia, edema, & hypoproteinemia
Reconsider
Elimination Diet
+
-
Reconsider
- Food Challenge
+
Reconsider
Specific Allergen Elimination Diet
Food Protein Induced Proctitis (Allergic Proctocolitis)
•  Gross blood in stool + other symptoms
Celiac Disease
•  Diarrhea, steatorrhea, malabsorption, abdominal
distention, flatulence, + nausea & vomiting, failure to
thrive, oral ulcers
•  Associated skin disease: dermatitis herpetiformis
Sampson HA JACI 103:981-9, 1999
DIAGNOSTIC APPROACH TO THE EVALUATION OF FOOD ALLERGY
Detailed History
+
IgE & Non-IgE-mediated
Allergic Eosinophilic Esophagitis,Gastritis, Gastroenteritis
•  Postprandial vomiting, early satiety, anorexia, abdominal
pain, hematemesis, steatorrhea, failure to thrive, weight
loss & gastric outlet obstruction
•  Subset with food-induced IgE-mediated reactions
Eosinophilic Esophagitis
-
Endoscopy
+
Infant
Reconsider
-
Elimination Diet
+
Reconsider
- Food Challenge
+
Reconsider
Specific Allergen Elimination Diet
Adult
•  Feeding aversion or
intolerance
•  Failure to thrive
•  Vomiting
•  Epigastric or chest pain
•  Dysphagia
•  Food impaction
Sampson HA JACI 103:981-9, 1999
IMMEDIATE HYPERSENSITIVITY
Symptoms
•  Cutaneous
•  Flushing, hives, angioedema, eczema
•  GI
•  Oropharyngeal pruritus and edema,
abdominal cramping, nausea, vomiting,
diarrhea
•  Pulmonary
•  Rhinitis, laryngeal edema, wheezing,
coughing & shortness of breath
•  Cardiovascular
•  Hypotension, tachycardia,
arrhythmias
•  Neurological
•  Loss of consciousness
•  Behavioral
•  Irritability (preceding or in
combination with other symptoms)
4
JACI cover July 2003
LINEAR VS CONFORMATIONAL EPITOPES
Sampson HA. JACI 113:805-19, 2004
Food Allergen Cross-Reactivity
5
DIAGNOSTIC APPROACH TO THE EVALUATION OF FOOD ALLERGY
Detailed History & Physical
+
+
+
IgE-mediated
IgE & Non-IgE-mediated
Non-IgE-mediated
PST or ImmunoCAP
-
GI Consultation/Endoscopy
+
+
Reconsider
-
Reconsider
Elimination Diet
-
Reconsider
+
Food Challenge
+
Specific Allergen Elimination Diet
-
Reconsider
Sampson HA JACI 103:981-9, 1999
Audience Response 1
A woman in the first trimester of her first pregnancy
calls to ask your advice about her diet because both
she and her husband have allergic rhinitis and were
allergic to milk as infants. Which of the following would
you suggest?
A.  Avoid the major allergenic foods (milk, egg, wheat,
soy, peanuts, tree nuts, fish and shellfish) during the
remainder of her pregnancy.
B.  Eat her usual diet, but avoid milk, peanuts and tree
nuts during the last trimester of her pregnancy.
C.  Eat her usual diet. Avoidance diets during pregnancy
are not currently recommended.
Case 1: Allan
History:
•  Both parents have seasonal allergic rhinitis and
were allergic to milk as infants
•  Term delivery by emergency C-section
–  Birth weight 7 lbs 15 ounces
•  Breast fed
–  Supplemented with Baby’s Only Organic Dairy Formula
•  No colic, growing, thriving
•  3 months old - developed a mild eczematous rash
6
Audience Response 2
Is Allan at high risk for the development of
allergic disease?
A.  Yes
B.  No
C.  Need more information in order to decide
Audience Response 3
Allan is 4 months old. His mother brings him in to ask
your recommendations for food introduction. Which of
the following would you recommend?
A.  Continue breast feeding and start adding in
complementary foods. Because he is high risk delay
introduction of the highly allergenic foods as
follows: dairy at 1 yr; egg at 2 yrs; peanuts, tree
nuts, fish and shellfish at 3 yrs.
B.  Continue breast feeding and add in complementary
foods 1 at a time every 3 to 5 days. After a few are
tolerated, allergenic foods can be added in the same
fashion at home (not day care or a restaurant).
Background
•  2000 – American Academy of Pediatrics
•  Milk – 1 year
•  Egg – 2 years
•  Peanuts, tree nuts, fish & shellfish – 3 years
•  2008 – American Academy of Pediatrics
•  No longer sufficient evidence to support
delayed introduction of allergenic foods
7
DUAL-ALLERGEN EXPOSURE HYPOTHESIS
Lack G. JACI 2008;121:1331-6
JACI: In Practice 2013;1:29-36
Summary of Recommendations:
•  Avoidance diets
–  Currently not recommended during pregnancy and lactation
•  Breast-feeding
–  Exclusive breast feeding is recommended for 4-6 months
•  To possibly reduce the incidence of atopic dermatitis in
the first 2 years of life
•  To reduce the incidence of cow’s milk allergy in the first
two years of life
•  To reduce early onset wheezing before 4 years of age
JACI: In Practice 2013;1:29-36
•  Selection of infant formula
–  For infants at increased risk of allergic disease who cannot
be exclusively breast-fed for the first 4 – 6 months of life,
hydrolyzed formula appears to offer advantages to prevent
allergic disease and cow’s milk allergy.
–  There is no substantial evidence that soy formula prevents
atopic disease.
–  There may be a slight benefit of an eHF over a pHF, but the
data are not conclusive.
–  Studies of amino-acid based formulas for the primary
prevention of allergic disease are lacking.
8
JACI: In Practice 2013;1:29-36
•  Introduction of complementary foods
–  Complementary foods can be introduced between 4 & 6
months of age
–  No current data are available to suggest that cow’s milk
protein (except for whole cow’s milk), egg, soy, wheat,
peanuts, tree nuts, fish and shellfish introduction into the
diet need to be delayed beyond 4-6 months of age.
–  Highly allergenic foods can be introduced once a few
complementary foods are tolerated first. They should be
introduced at home.
JACI: In Practice 2013;1:29-36
•  Refer to an allergist for testing before the
introduction of highly allergenic foods if
the patient…
– Has had an allergic reaction to a food
– Is suspected of having an underlying food
allergy
– Has difficult to control moderate to severe
atopic dermatitis
Questions from the Trenches
•  How do the AAP and AAAI statements around food
introduction conflict, and how can they be reconciled?
•  What are the current recommendations around lactation and
food avoidance? What about during pregnancy?
•  What are the current theories as to why food sensitization
occurs? What role does this child’s eczema play? FH?
•  Are there foods that should continue to be avoided in the first
year of life or under certain circumstances.
•  Can you comment on the recent NEJM study regarding early
introduction of peanuts and the implications for practitioners?
9
Case 1: Allan
History cont’d:
•  5 months old – tolerated first oatmeal feeding
•  1 week later – fed different brand of oatmeal
–  3 hours later – vomited 6 times and a couple of
hours later had several loose stools
•  Several days later – fed oatmeal again with similar
reaction (timing and symptoms)
•  Waited 2 weeks, gave oatmeal again
–  3 hours later vomiting, pale & lethargic
–  Recovered after 3 hours
•  Oatmeal removed from his diet
Audience Response 4
Allan’s mother brings him after his third reaction to
oatmeal. She asks your opinion about the cause of the
reactions? Which of the following would you tell her?
A.  The family history of allergies, his atopic dermatitis,
and the reproducibility and timing of reactions
suggest this is an IgE-mediated oat allergy.
B.  The symptoms, reproducibility and delayed timing of
the reaction are consistent with FPIES to oats.
C.  Oats rarely cause allergic reactions. This is most
likely an oat intolerance that will resolve by the time
he is a year old.
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
What is FPIES?
FPIES is a non-IgE-mediated food allergy that
usually presents in young infants and manifests
as profuse repetitive vomiting and lethargy,
typically occurring 2 to 4 hours after ingestion
of the offending allergen and occasionally
followed by diarrhea several hours later.
Caubet JC, et al, JACI 2014;134:382-9
10
FOOD TRIGGERS OF FPIES
Caubet JC, et al, JACI 2014;134:382-9
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
Key Features
•  Onset in infancy
• 
• 
• 
• 
60% male
Occurs usually in formula-fed, not breast-fed infants
Tolerate breast milk and extensively hydrolyzed formulas
Allergy to both milk and soy occurs in ~ 50%, may
involve other foods
•  History of allergic disease
•  Family: atopy 75%, food allergy 20%
•  Personal: atopic dermatitis 25%, asthma/rhinitis 20%
Sicherer S. JACI 2005;115:149
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
Key Features
•  Skin tests & serum food-specific IgE levels are
classically negative
•  Clinical course: resolution between 2 - 5 years
of age
•  Two clinical patterns:
•  Chronic exposure
•  Acute exposure after period of avoidance
Maloney J, Nowak-Wegryzn A. Pediatr Allergy Immunol 2007;18:360-7
11
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
Chronic exposure pattern
•  Symptoms/lab findings
– 
– 
– 
– 
– 
– 
– 
– 
Vomiting
Diarrhea (blood, reducing substances positive)
Lethargy
Failure to thrive
Dehydration
Hypotension
Methemoglobinemia
Maloney J, Nowak-Wegryzn A. Pediatr
Hypoalbuminemia
Allergy Immunol 2007;18:360-7
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
Acute exposure after avoidance pattern
•  Symptoms/lab findings
– 
– 
– 
– 
– 
Onset of vomiting: ~ 2 hours after ingestion
Onset of diarrhea: ~ 5 hours after ingestion
Lethargy
Elevated neutrophil count
~ 15% progress to hypotension, acidemia,
methemoglobinemia
Maloney J, Nowak-Wegryzn A. Pediatr Allergy Immunol 2007;18:360-7
FOOD PROTEIN-INDUCED
ENTEROCOLITIS SYNDROME (FPIES)
•  Diagnosis
–  Typical clinical pattern with negative skin tests
–  Need for food challenge determined on clinical grounds
•  Treatment
• 
• 
• 
• 
• 
• 
Eliminate offending food, symptoms resolve
If food ingested, proceed to medical care
Treat acute reactions with vigorous IV hydration, ondansetron
Epinephrine and antihistamine not helpful
Typically resolves by 4-5 years of age
Reintroduction of food under physician supervision with IV
access
Sicherer S. JACI 2005;115:149
12
Case: Allan
•  You are seeing him for a 9 month old visit. He has
eczema and the parents are wondering if it could be
secondary to food allergies. The family has been
uncomfortable with the topical steroid prescribed for
them at the last visit and they try their best to apply
daily lubricant but admit compliance is challenging.
The family is requesting food allergy testing.
ARS #5
You recommend the following:
1) ImmunoCAP food panel testing and if anything is
positive, then food avoidance and allergy referral.
2) Refer this child to an allergist for skin testing in
conjunction with ImmunoCAP testing.
3) Recommend improved skin care to get this child’s
skin under control, and do not do food allergy testing
at this time.
Questions from the Trenches
•  What is the role of ImmunoCAP testing to foods in
this situation? How reliable is it in predicting food
allergies. What is the Choose Wisely Campaign
and what is the recommendation in this situation?
•  Which infant with eczema really needs to see an
allergist in the first year of life? What is the
likelihood of food allergies in this patient?
13
Case 1: Allan
History cont’d:
•  12 months old, still breast fed - has persistent mild
to moderate atopic dermatitis
•  On a Sunday morning his mother fed him about
1/10 tsp of peanut butter at home. Within 5 minutes
he became irritable, vomited and developed a few
perioral hives. His mother gave him a dose of
diphenhydramine. He calmed down and recovered
uneventfully, without further symptoms.
•  The next morning she called and brought him to
your office for evaluation.
Audience Response 6
Allan looks fine in your office the next morning except
for a mild eczema flare. He has not eaten other nuts.
Which of the following would you do?
A.  Educate about peanut and tree nut avoidance and
refer him to an allergist.
B.  Educate about peanut and tree nut avoidance. Give
an Epipen Jr prescription and a Food Allergy Action
Plan. Order an ImmunoCAP to peanut and common
tree nuts. Tell her you will consider referral to an
allergist when he is older and skin tests are more
reliable.
C.  Educate about peanut and tree nut avoidance. Give
EpiPen Jr prescription & FAAP. Refer to an allergist.
Questions from the Trenches
•  If this child came into see you right after the ingestion, would
• 
• 
• 
• 
• 
epinephrine have been indicated? What are the indications
for epinephrine? What are best in office strategies after
ingestion?
Is an ImmunoCAP test helpful acutely in this situation? How
does the ImmunoCAP value help you and what do you tell
this family about the natural course of this particular allergy?
Should the family be instructed to not feed this child any
nuts?
Does this child need to see an allergist?
What advice do you give this family around precautions and
preventing accidental exposures in the daycare
environment?
What are the indications for an oral challenge in the future?
14
Case 1: Allan
History cont’d:
•  Allan was seen by an allergist
–  Skin testing was performed to selected food allergens
–  Positive skin tests to egg (6x4), peanut (11x10), sesame
(10x10)
–  Negative skin tests to milk, tree nuts, oat, wheat, soy,
fish mix and shrimp
–  ImmunoCAPs ordered: egg white 10.6, peanut 6.82,
sesame 0.69
–  Use of auto-injectable epinephrine, Food Allergy Action
Plan and treatment of reactions reviewed
–  Egg, peanut and sesame removed from diet
–  Education regarding avoidance provided
•  Atopic dermatitis improved
ARS 7
Which one of the following statements is false?
A.  Skin tests and ImmunoCAPs predict the severity of
future reactions upon exposure to a food.
B.  Skin tests and immunoCAPs predict the likelihood of
reacting upon exposure to a food.
C.  If the history is convincing and the immunoCAP is
negative, performing a skin test to the food is
indicated.
D.  If the history is convincing and the skin test and
immunoCAP are negative, a careful oral food
challenge under medical supervision, rather than
eating the food at home is the preferred approach.
SENSITIZATION VS CLINICAL REACTIVITY
•  Sensitization
•  Presence of food-specific IgE detected by skin
testing or in vitro testing (FEIA)
•  Overestimates prevalence
•  Clinical reactivity
•  Evidence of symptoms upon exposure to a food
•  History
•  Challenge
15
DIAGNOSTIC APPROACH TO THE EVALUATION OF FOOD ALLERGY
Detailed History
Epicutaneous skin testing
+
•  Glycerinated commercial extracts 1:10 or 1:20
weight/volume
•  Consider freshly prepared extracts for fruits and
vegetables or if no commercial extract
IgE-mediated
+
- PST and/or ImmunoCAP •  Applied by prick or puncture technique
– Intradermal technique is not recommended
•  Positive predictive accuracy
– Less than 50% (many “false” positives)
•  Negative predictive accuracy
– Greater than 95% (few “false” negatives)
+
Reconsider
-
Elimination Diet
+
Reconsider
-
Food Challenge
+
Reconsider
Select skin tests based on history and major
foods known to cause symptoms.
Specific Allergen Elimination Diet
Sampson HA JACI 103:981-9, 1999
Summary Statement 23:
The clinician should use specific IgE tests to foods as
diagnostic tools; however, testing should be focused
on foods suspected of provoking the reaction, and test
results alone should not be considered diagnostic of
food allergy.
PRICK SKIN TESTING
Sporik R,et al, Clin Exp Allergy 2000; 30:
1540-6
–  467 infants and children (median age 3 yrs)
referred to center over 9 yrs (1989-98)
–  Prick skin testing to milk, egg, peanut
–  555 open food challenges
•  Results
–  Positive challenge was always seen when
SPT was above a certain size
•  Milk & Peanut > 8 mm
•  Egg > 7 mm
–  In children < 2 yrs SPT sizes were smaller
•  Milk > 6 mm
•  Egg > 5 mm
•  Peanut > 4 mm
16
Skin prick testing (SPT)
• 
• 
• 
• 
• 
Safe and useful for diagnosis of IgE-mediated food allergy
Reagents and methods are not standardized
Use of large panels is discouraged
Intradermal testing not indicated
Positive SPT correlates with the presence of allergen-specificIgE bound to the surface of cutaneous mast cells.
•  Compared with oral food challenges they have low specificity
and low positive predictive value for making an initial diagnosis
of FA.
•  Wheal size has not been correlated to disease severity.
•  The larger the mean wheal provoked, the more likely that a
food allergen will be of clinical relevance.
Skin prick testing (SPT)
•  In children at high risk skin testing may be considered before
introduction of certain foods.
•  In a cohort of infants with milk and/or egg allergy 69% were
sensitized to peanut.
•  When diagnosing OAS, or in cases where SPT with commercial
extracts do not correlate with the clinical histories, the SPT
technique with fresh or native foods, especially fruits and
vegetables, may prove more sensitive. (fresh fruits can be frozen
an reused)
•  Skin test sizes vary with age, skin test location, device and extract
used.
•  Negative skin test in face of highly suggestive history- consider
medically supervised food challenge
DIAGNOSTIC APPROACH TO THE EVALUATION OF FOOD ALLERGY
Detailed History
+
IgE-mediated
+
-
PST or ImmunoCAP
+
Reconsider Dx
Elimination
Diet
+
Reconsider Dx
- Food Challenge
+
Reconsider Dx
Specific Allergen Elimination Diet
Sampson HA JACI 103:981-9, 1999
17
Allergen-specific serum IgE
•  Useful for diagnosis of IgE-mediated food allergy, but
not diagnostic
•  “Cutoff” levels, defined at 95% predictive values may be
more predictive than SPTs of clinical reactivity in certain
populations
•  Fluorescence-labeled antibody assays have
comparable sensitivity to that of SPT
•  Different assays yield variable results
•  Absolute levels of sIgE may directly correlate with the
likelihood of clinical reactivity when compared with OFC
Allergen-specific serum IgE
•  Predictive values vary among studies
•  Patient selection (patients’ ages)
•  Clinical disorder studied
•  Length of food avoidance
•  Negative test in face of highly suggestive historyconsider medically supervised food challenge
Predictive value of IgE testing in
positive or negative OFC results
18
IMMUNOCAP
PROBABILITY OF REACTING TO A FOOD
AT A GIVEN IGE VALUE
Sampson HA. JACI 113:805-19, 2004
TREATMENT: PATIENTS AND CARETAKERS
• 
• 
• 
• 
Recognition of early signs and symptoms
How and when to give epinephrine (written plan)
Administration of liquid or chewable antihistamine
Ambulance to emergency room
TREATMENT: MEDICAL PERSONNEL
•  Assess rapidly and provide supportive care
•  Medications:
–  Oxygen
–  Epinephrine
–  IV Fluids
- Antihistamines
- Bronchodilators
- Steroids
EpiPen Injection Site
•  Pay attention to factors that might inhibit response
to treatment
•  Observe for relapse
•  Provide prescription for auto-injectable epinephrine
device
•  Arrange follow-up care
19
FATALITIES DUE TO ANAPHYLACTIC REACTIONS TO FOODS
Bock SA, et al. JACI 2001;107:191-3 (update JACI 2007;119:1016-18)
•  Analyzed 32 cases reported to national registry
•  Identified food
–  Peanut: 20 cases
–  Tree nuts: 10 cases
–  Milk & fish: 1 case each
• 
• 
• 
• 
• 
Both sexes equally affected (16 F/16M)
Most were adolescents or young adults (r: 2-32 years)
Previous knowledge of food allergy- all, but one
Most reactions occurred outside of the home (27/32)
Asthmatics at higher risk
–  24 of 25 with complete data had asthma
•  Lack of availability of epinephrine at the time of the reaction
(4/32 had epinephrine available)
–  4 who received epinephrine in a timely fashion still died
Patient factors
+
•  Complicating medical issues
– Asthmatic
– On medication that might interfere
with response to treatment
- β-blocker
•  Food allergy
– Peanut or tree nut sensitive
•  Level of sensitivity
– Previous reaction patterns
•  Target organ
•  Life-threatening
Event factors
•  Food involved
– Peanuts, tree nuts
•  Route of exposure
– Contact, inhalation, ingestion,
injection
•  Dose
•  Target organ system
– Pulmonary, cardiovascular, GI,
cutaneous
•  Treatment
•  Response to treatment
•  Maturity/psychosocial issues
Severity of reaction
TREATMENT: FOLLOW-UP VISIT
AFTER ALLERGIC REACTION
•  Monitor response to treatment
•  Review circumstances leading to the reaction
•  Review effectiveness of Food Allergy Action Plan
•  Make necessary alterations
•  Review importance of medic-alert bracelet or
other form of identification as food allergic
•  Provide emotional support
20
Bird JA, et al, JACI Pract 2015;3:1-11.
Web-based Resources for Food Allergies
Bird JA, et al, JACI Pract 2015;3:1-11.
Bird JA, et al, JACI Pract
2015;3:1-11.
21
LONG TERM MANAGEMENT
•  Follow-up visits at appropriate intervals
•  History
•  Determine frequency & specifics of reactions
•  Exposure to offending foods without a reaction?
•  Review current diet
•  Development of allergies to other foods?
•  Routinely carrying treatment medications?
•  Impact of food allergy on quality of life?
•  Development of other allergic disease (asthma)?
LONG TERM MANAGEMENT
•  Physical examination
•  Appropriate weight gain
•  Findings suggestive of new allergic disease or
other disease
•  Laboratory data
•  Skin testing?
•  ImmunoCAP?
•  Other testing suggested by history?
LONG TERM MANAGEMENT
•  Management
•  Reinforce need to carry medications at all times and review use
of medical devices (epinephrine auto-injector, inhaler if asthmatic)
•  Food challenge indicated by history and/or lab results?
•  Aid in interactions with school and community
•  Answer questions
•  Suggestions regarding impact on quality of life
•  Is referral indicated
•  Allergist
•  Gastroenterologist
•  Dietician
•  Psychosocial clinician
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FOOD ALLERGY: INDICATIONS FOR
REFERRAL TO THE ALLERGIST
•  Diagnostic assessment of the patient with:
–  Severe or persistent disease
–  Multiple food sensitivity
–  Complications
–  Coexisting allergic disease (asthma, atopic dermatitis)
• 
• 
• 
• 
• 
Test interpretation
Identification of offending foods
Performance of food challenges
Development of targeted elimination diets
Comprehensive patient education
QUESTIONS
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Oatmeal Studios
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