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Page 1: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Food AllergyFood Allergy

Page 2: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Adverse Food Reactions Adverse Food Reactions

Toxic / PharmacologicToxic / Pharmacologic Non-Toxic / IntoleranceNon-Toxic / IntoleranceBacterial food Bacterial food poisoningpoisoningHeavy metal poisoningHeavy metal poisoningScombroid fish Scombroid fish poisoningpoisoningCaffeineCaffeineAlcoholAlcoholHistamineHistamine

Non-immunologic

Lactase deficiencyLactase deficiencyGalactosemiaGalactosemiaPancreatic insufficiencyPancreatic insufficiencyGallbladder / liver Gallbladder / liver diseasediseaseHiatal herniaHiatal herniaGustatory rhinitisGustatory rhinitisAnorexia nervosaAnorexia nervosaIdiosyncraticIdiosyncratic

Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol 2006;117:S470-475.

Page 3: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Eosinophilic Eosinophilic esophagitisesophagitis

Eosinophilic gastritisEosinophilic gastritis

Eosinophilic Eosinophilic gastroenteritisgastroenteritis

Atopic dermatitisAtopic dermatitis

Adverse Food Reactions Adverse Food Reactions

IgE-MediatedIgE-Mediated(most common)(most common)

Non-IgE MediatedNon-IgE MediatedCell-MediatedCell-Mediated

Immunologic

Systemic Systemic (Anaphylaxis)(Anaphylaxis)

Oral Allergy Oral Allergy SyndromeSyndrome

Immediate Immediate gastrointestinal gastrointestinal allergyallergy

Asthma/rhinitisAsthma/rhinitis

UrticariaUrticaria

Morbilliform rashes Morbilliform rashes and flushingand flushing

Contact urticariaContact urticaria

Protein-Induced Protein-Induced EnterocolitisEnterocolitis

Protein-Induced Protein-Induced EnteropathyEnteropathy

Eosinophilic proctitisEosinophilic proctitis

Dermatitis herpetiformisDermatitis herpetiformis

Contact dermatitisContact dermatitis

Sampson H. J Allergy Clin Immunol 2004;113:805-9, Chapman J et al. Ann Allergy Asthma & Immunol 2006;96:S51-68.

Page 4: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Public PerceptionPublic Perception

25% of the population – at least 1 member of 25% of the population – at least 1 member of their family had “food allergy”their family had “food allergy”

Adults surveyed – 20% report they have a Adults surveyed – 20% report they have a “food intolerance” and alter their diet for “food intolerance” and alter their diet for perceived adverse reaction to foodperceived adverse reaction to food

Page 5: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Prevalence – Food Allergy in ChildrenPrevalence – Food Allergy in ChildrenWhat is the est. prevalence under 3 yrs old? What is the est. prevalence under 3 yrs old?

6% (2004)6% (2004)

Fish – 0.1%Fish – 0.1% Shellfish – 0.1%Shellfish – 0.1%

Tree nuts – 0.2%Tree nuts – 0.2%

Soy – 0.4%Soy – 0.4% Wheat – 0.4%Wheat – 0.4%

Food Additives – 0.5-1%Food Additives – 0.5-1%

Peanut – Peanut – 0.8%0.8% (0.5-1%) (0.5-1%)

Egg – 1.3% (2003) young kidsEgg – 1.3% (2003) young kids

Cow’s milk allergy – in 1st yr – 2.5%Cow’s milk allergy – in 1st yr – 2.5%

Asthmatic kids – 6% food induced wheezingAsthmatic kids – 6% food induced wheezing

Mod to severe AD – 35% food allergiesMod to severe AD – 35% food allergies

Page 6: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Prevalence - Food Allergy in AdultsPrevalence - Food Allergy in Adults

What is est. prevalence in adults?What is est. prevalence in adults? 3-4% U.S3-4% U.S. (3.7% - 2004), (2% - 1999). (3.7% - 2004), (2% - 1999)Food additives – 0.01-0.23%Food additives – 0.01-0.23%Fish – 0.4%Fish – 0.4%Tree nut – 0.5%Tree nut – 0.5%Peanut – 0.6% (Total peanut & tree nut 1.1%)Peanut – 0.6% (Total peanut & tree nut 1.1%)Shellfish – (2% - 2004), (0.5% - 1996)Shellfish – (2% - 2004), (0.5% - 1996)Fruits, veggies – common (Fruits, veggies – common (~~5%) but not severe5%) but not severeSesame – increasingly reportedSesame – increasingly reportedAdults with AD – rare food allergyAdults with AD – rare food allergyAdults with asthma – rare food allergyAdults with asthma – rare food allergy

Page 7: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Natural HistoryNatural HistoryMilk allergy – 50% lose reactivity by 1 yrs, Milk allergy – 50% lose reactivity by 1 yrs, 70% by 2 yrs, 85% by 3 yrs70% by 2 yrs, 85% by 3 yrs 35% with milk IgE at 1 year had other food 35% with milk IgE at 1 year had other food

allergies by 3 yrs, 25% had FA at 10 yrs allergies by 3 yrs, 25% had FA at 10 yrs

Egg, soy & wheat – Egg, soy & wheat – 80% resolve by school age80% resolve by school age

Peanut allergy – What percent lose reactivity?Peanut allergy – What percent lose reactivity? 20% by age 5 (1998, 2003), but it may recur20% by age 5 (1998, 2003), but it may recur

Adults can also lose reactivity with avoidanceAdults can also lose reactivity with avoidance

Skin test can remain + but no rxn on DBPCFCSkin test can remain + but no rxn on DBPCFC

Page 8: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

CASE: Crustacean Allergy: IgE Towards CASE: Crustacean Allergy: IgE Towards Protein in the Food, NOT Iodine Protein in the Food, NOT Iodine

79 year old man had anaphylaxis to shrimp at age 20, 2579 year old man had anaphylaxis to shrimp at age 20, 25

Doctors told him he was allergic to Doctors told him he was allergic to iodineiodine in seafood in seafood

Avoided seafood, Avoided seafood, iodizediodized salt for years salt for years

Age 70: retirement dinner, hostess picked shrimp out of his portion Age 70: retirement dinner, hostess picked shrimp out of his portion and gave it to him --- ER visit for anaphylaxisand gave it to him --- ER visit for anaphylaxis

At age 79, specific IgE measurement extremely high to shrimp: At age 79, specific IgE measurement extremely high to shrimp: >100 kU/L >100 kU/L

On follow-up after education on avoidance, happily consuming On follow-up after education on avoidance, happily consuming foods with iodized salt because he didn’t have to screen salt foods with iodized salt because he didn’t have to screen salt source any moresource any more

Page 9: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Gastrointestinal Barriers to Ingested Gastrointestinal Barriers to Ingested Food AntigensFood Antigens

Immunologic barriersImmunologic barriers Block penetration of ingested antigens:Block penetration of ingested antigens:

Antigen-specific s-IgA in gut lumenAntigen-specific s-IgA in gut lumen

Clear antigens penetrating GI barrier:Clear antigens penetrating GI barrier:

Serum antigen-specific IgA and IgGSerum antigen-specific IgA and IgG

Reticulo-endothelial system Reticulo-endothelial system

Physiologic barriersPhysiologic barriers Breakdown of ingested antigens:Breakdown of ingested antigens:

Gastric acid and pepsinsGastric acid and pepsins

Pancreatic enzymesPancreatic enzymes

Intestinal enzymesIntestinal enzymes

Intestinal epithelial cell lysozyme Intestinal epithelial cell lysozyme activityactivity

Block penetration of ingested antigens:Block penetration of ingested antigens:Intestinal mucus coat (glycocalyx)Intestinal mucus coat (glycocalyx)

Intestinal microvillus membrane Intestinal microvillus membrane compositioncomposition

Intestinal peristalsisIntestinal peristalsis

Page 10: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Figure 2-15 The mucosal immune system

Page 11: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

GALT – induces toleranceGALT – induces tolerance

M Cells overlie Peyer’s Patches (PPs), M Cells overlie Peyer’s Patches (PPs), primarily in distal small intestineprimarily in distal small intestine

M cells have lectin-like receptors which M cells have lectin-like receptors which sample antigens (large) from gut lumensample antigens (large) from gut lumen

Ags taken-up by macrophages and carried Ags taken-up by macrophages and carried to resident T and B cells in PPsto resident T and B cells in PPs

All Ig classes can be produced after oral All Ig classes can be produced after oral antigen, IgM+ B cells primarily switched to antigen, IgM+ B cells primarily switched to IgA+ B cellsIgA+ B cells

Page 12: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Oral ToleranceOral Tolerance

Deletion – only with very high antigen doseDeletion – only with very high antigen dose

AnergyAnergy Intestinal epithelial cells (IECs) – non-professional Intestinal epithelial cells (IECs) – non-professional

APC’s – Class II MHC, but no 2APC’s – Class II MHC, but no 2ndnd signals signals Dendritic cells in PPs (non-inflam environment) express Dendritic cells in PPs (non-inflam environment) express

IL10 and IL4 which favor toleranceIL10 and IL4 which favor tolerance

Figure 10-1 Fates of lymphocytes after encounter with antigens

Page 13: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Failure of Oral Tolerance

Food-specific IgE Abs bind to FcER1 on mast cells and basos

Exposure to Ag - immediate release of vasoactive amines (histamine) – hives, wheezing, shock

Delayed or chronic response - cell mediated or cytokine release (TNF-a, IL-5) and most commonly affect gut

Figure 19-1 Sequence of events in immediate hypersensitivity reactions

Page 14: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Oral Allergy Syndrome/Pollen-Oral Allergy Syndrome/Pollen-Food Allergy SyndromeFood Allergy Syndrome

Mucosal equivalent of Mucosal equivalent of urticariaurticariaItching and swelling of the mouth & oropharynx Itching and swelling of the mouth & oropharynx May lead to refusal of the foodMay lead to refusal of the food

Assoc with rhino-conjunctivitis and pollen allergy Assoc with rhino-conjunctivitis and pollen allergy Birch – apple, cherry, pear, kiwi, carrot, potato, celery, Birch – apple, cherry, pear, kiwi, carrot, potato, celery, hazelnuthazelnutMugwort – Carrot, celery, parsley, fennelMugwort – Carrot, celery, parsley, fennelRagweed – Melon, bananaRagweed – Melon, bananaGrass – Kiwi, watermelon, tomato, potatoGrass – Kiwi, watermelon, tomato, potatoSx may improve with allergy immunotherapySx may improve with allergy immunotherapyCan treat with anti-histaminesCan treat with anti-histamines

Page 15: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Latex-Fruit Latex-Fruit SyndromeSyndrome

30-50% of those with latex allergy are sensitive to 30-50% of those with latex allergy are sensitive to some fruits due to cross-reactive IgEsome fruits due to cross-reactive IgE

Most common fruits: banana, avocado, kiwi, chestnut Most common fruits: banana, avocado, kiwi, chestnut but other fruits and nuts have been reportedbut other fruits and nuts have been reported

Can clinically present as anaphylaxis to fruitCan clinically present as anaphylaxis to fruit

Warn latex-sensitive patients of potential cross-Warn latex-sensitive patients of potential cross-reactivityreactivity

Some fruit-allergic patients may be at risk for latex Some fruit-allergic patients may be at risk for latex allergyallergy

Page 16: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Evaluation of Food AllergiesEvaluation of Food AllergiesHistory:History:

1.1. What food responsible?What food responsible?

2.2. Quantity of foodQuantity of food

3.3. Time courseTime course

4.4. Similar prior symptomsSimilar prior symptoms

5.5. Other factors necessary (exercise, Other factors necessary (exercise, fevers, EtoH)fevers, EtoH)

6.6. When was last reaction?When was last reaction?

Food diaries – causal foods, “hidden” Food diaries – causal foods, “hidden” ingredientsingredients

Page 17: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Skin TestingSkin TestingSkin Prick test – 95% negative predictive value in Skin Prick test – 95% negative predictive value in people > 3 yrs – people > 3 yrs – If negative SPT – food challengeIf negative SPT – food challengeIn kids < 3 years, only 80-85% negative predictive In kids < 3 years, only 80-85% negative predictive valuevalueOnly 50% PPV – IgE present, but they can tolerate Only 50% PPV – IgE present, but they can tolerate the food (atopic derm)the food (atopic derm)Wheal 3 mm greater than neg. Wheal 8 mm.Wheal 3 mm greater than neg. Wheal 8 mm.If positive prick with convincing history of If positive prick with convincing history of anaphylaxis – restrict the foodanaphylaxis – restrict the foodFatalities reported after intradermal testingFatalities reported after intradermal testingFruits, veggies (apples, orange, bananas, potatoes, Fruits, veggies (apples, orange, bananas, potatoes, carrots, celery) – extract not stable – prick-prickcarrots, celery) – extract not stable – prick-prick

Page 18: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

TestingTestingOlder RASTs and paper disk 1Older RASTs and paper disk 1stst gen EIAs gen EIAs

Quantitative specific IgE (CAP-FEIA; Quantitative specific IgE (CAP-FEIA; Pharmacia) – 2Pharmacia) – 2ndnd generation – predictive generation – predictive values for reactionsvalues for reactions

Suspect non-IgE – biopsy of gut, skinSuspect non-IgE – biopsy of gut, skin

Suspect non-allergic – sweat, breath H+, Suspect non-allergic – sweat, breath H+, endoscopyendoscopy

Unproven/experimental – Unproven/experimental – provocation/neutralization, cytotoxic tests, provocation/neutralization, cytotoxic tests, kinesiology, hair analysis, IgG4kinesiology, hair analysis, IgG4

Page 19: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Levels of Specific IgE Yielding Predictive Values for CAP-RAST Tests

Food 95 % positivepredictive value

95 % negativepredictive value

Milk 32 0.8

Egg 6 90 % at 0.6

Peanut 15 85 % at <0.35

Soy 50% at 65 2

Wheat 75 % at > 100 5

Fish 20 0.9

Sampson HA, Ho DG. J Allergy Clin Immunol 1997;100:444-51.

Page 20: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Elimination Diets and Food Elimination Diets and Food ChallengesChallenges

Elimination DietsElimination Diets Eliminate suspected food(s), orEliminate suspected food(s), or Prescribe limited “eat only” diet, orPrescribe limited “eat only” diet, or Elemental dietElemental diet

Oral Challenge (MD, Crash cart)Oral Challenge (MD, Crash cart) OpenOpen Single-blindSingle-blind Gold Standard to diagnose FAs – DBPCFCGold Standard to diagnose FAs – DBPCFC If DBPCFC is negative, must follow w open If DBPCFC is negative, must follow w open

challenge (1-3% false neg challenge)challenge (1-3% false neg challenge)

Page 21: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

AnaphylaxisAnaphylaxis

94%94% of fatal food anaphylaxis involve peanuts or tree nuts (63% peanut, 31% tree)*

Page 22: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Fatalities Due To Anaphylaxis To Fatalities Due To Anaphylaxis To Foods*Foods*

32 fatal cases from 1994-1999 analyzed 32 fatal cases from 1994-1999 analyzed

Peanut accounted for Peanut accounted for 63%63% of fatalities of fatalities Other nuts: Other nuts: 31%31%

AllAll ingestions were ingestions were “accidental”“accidental”84%84% occurred outside of home occurred outside of home

All but 1 had All but 1 had asthmaasthma (97%) (97%)

Epinephrine was Epinephrine was NOT NOT given or was given very given or was given very late in late in 88%88%

**JACIJACI 2001;107:191-1932001;107:191-193

Page 23: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Treatment: EducationTreatment: EducationAnaphylactic SymptomsAnaphylactic Symptoms

Erythema, flushing or pruritusErythema, flushing or pruritus

Urticaria and angioedemaUrticaria and angioedema

Nasal, ocular, and palatal pruritus Nasal, ocular, and palatal pruritus

Sense of impending doomSense of impending doom

Gastrointestinal symptomsGastrointestinal symptoms

Uterine crampsUterine cramps

Dizziness, syncope, loss of Dizziness, syncope, loss of consciousnessconsciousness

Page 24: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Anaphylactic SymptomsAnaphylactic Symptoms

Upper airway obstructionUpper airway obstruction HoarsenessHoarseness Dysphonia (altered voice)Dysphonia (altered voice) Difficulty swallowing.Difficulty swallowing.

Lower airway obstructionLower airway obstruction WheezingWheezing Chest tightnessChest tightness

Page 25: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning
Page 26: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Treatment: AvoidanceTreatment: Avoidance……Easier Said Than DoneEasier Said Than Done

www.foodallergy.org - FAAN - FAAN25% of labels may not reflect presence of peanut25% of labels may not reflect presence of peanut11

Sensitive patients may react to trace amounts of Sensitive patients may react to trace amounts of peanut (as low as 100 mcg)peanut (as low as 100 mcg)Contact with or inhalation of peanut might occur Contact with or inhalation of peanut might occur on airlineson airlines22

Cross Contamination (shared equipment)Cross Contamination (shared equipment)Hidden ingredientsHidden ingredientsMost common places: Most common places:

Asian restaurants, bakeries and ice cream shops. Asian restaurants, bakeries and ice cream shops. DessertsDesserts

1.1.www.cfsan.fda.gov/~dms/alrgpart.html2. 2. JACI JACI 1999;104:186-91999;104:186-9

Page 27: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Less than 20 kg – Epi Pen Jr Less than 20 kg – Epi Pen Jr (0.15 mg)(0.15 mg)

Over 30 kg – Epi Pen (0.3 mg)Over 30 kg – Epi Pen (0.3 mg)

Between 20-30 kg – Depends Between 20-30 kg – Depends on historyon history

If asthma, h/o anaphylaxis, or If asthma, h/o anaphylaxis, or peanut allergy – Give higher peanut allergy – Give higher (adult) dose 0.3 mg(adult) dose 0.3 mg

Children: 0.01 ml/kg, Children: 0.01 ml/kg, maximum of 0.5 ml maximum of 0.5 ml

Repeated every 5-15 minutes Repeated every 5-15 minutes for two doses and then every 4 for two doses and then every 4 hours (more if needed)hours (more if needed)

Adult: 0.3 ml to 0.5 ml of a Adult: 0.3 ml to 0.5 ml of a 1:1000 dilution 1:1000 dilution subcutaneously or subcutaneously or intramuscularlyintramuscularly

Repeated every 5 to 15 minutes Repeated every 5 to 15 minutes (more PRN)(more PRN)

Epinephrine

Page 28: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Fatal and near-fatal anaphylactic reactions to food Fatal and near-fatal anaphylactic reactions to food in children and adolescents*in children and adolescents*

6 fatal 6 fatal Symptoms 3-30 minutesSymptoms 3-30 minutes Only 2 had epinephrine in first hourOnly 2 had epinephrine in first hour 3 Uniphasic, rapid progression3 Uniphasic, rapid progression 33 Biphasic: Early mild symptoms followed by 1-Biphasic: Early mild symptoms followed by 1-

2 hours asymptomatic; then resp and CV sx2 hours asymptomatic; then resp and CV sx

7 non-fatal7 non-fatal Symptoms within 5 minutesSymptoms within 5 minutes 7/7 received epinephrine within 30 minutes7/7 received epinephrine within 30 minutes 4 Uniphasic: Severe symptoms w/in 30 minutes4 Uniphasic: Severe symptoms w/in 30 minutes 3 Protracted anaphylaxis: Ventilatory support 3 Protracted anaphylaxis: Ventilatory support

and vasopressor meds for > 24 hours (one for 3 and vasopressor meds for > 24 hours (one for 3 weeks!)weeks!)

Page 29: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

www.americanmedical-id.comwww.americanmedical-id.com

Food Allergy Action Plan

Page 30: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Other Medications…Other Medications…

H1 receptor antagonist (Diphenhydramine - H1 receptor antagonist (Diphenhydramine - Benadryl)Benadryl) 1 to 2 mg/kg or 25 to 50 mg/dose parenterally1 to 2 mg/kg or 25 to 50 mg/dose parenterally

Ranitidine (Zantac) Ranitidine (Zantac) H2 receptor antagonistH2 receptor antagonist When combined with an H1 type may be useful in When combined with an H1 type may be useful in

reversing reversing hypotension refractory to hypotension refractory to epinephrineepinephrine and intravascular fluid replacement and intravascular fluid replacement

Adult Dose: 50 mg/dose IV/IM q6-8hAdult Dose: 50 mg/dose IV/IM q6-8h

Albuterol, racemic EpinephrineAlbuterol, racemic Epinephrine

Page 31: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Other MedicationsOther MedicationsGlucagon Glucagon 1-5 mg (20-30 mcg/kg) over 5 min by infusion of 5-1-5 mg (20-30 mcg/kg) over 5 min by infusion of 5-

15 mcg/min titrated to clinical response15 mcg/min titrated to clinical response Maintains blood pressure independent of Maintains blood pressure independent of

adrenergic receptors by increasing intracellular adrenergic receptors by increasing intracellular cyclic AMPcyclic AMP

Stimulates release of endogenous catecholaminesStimulates release of endogenous catecholamines

CorticosteroidsCorticosteroids 200 mg hydrocortisone IV200 mg hydrocortisone IV Efficacy of corticosteroids in acute anaphylaxis or in Efficacy of corticosteroids in acute anaphylaxis or in

reducing a late anaphylactic reaction has not been reducing a late anaphylactic reaction has not been clearly established clearly established

Page 32: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Can Food Allergies be Can Food Allergies be Prevented? 50 year debatePrevented? 50 year debate

Who should we target?Who should we target? ““Allergy Genes” – Genome Project – 11q13 Allergy Genes” – Genome Project – 11q13

(IgE receptor), 5q31-33 (cytokine genes), 6p21 (IgE receptor), 5q31-33 (cytokine genes), 6p21 (HLA-D region)(HLA-D region)

Family history – 1 allergic parent – risk Family history – 1 allergic parent – risk atopyatopy 40-60%, 2 allergic parents – 60-80%40-60%, 2 allergic parents – 60-80%

Sensitivity of fam hx in predicting Sensitivity of fam hx in predicting food allergyfood allergy only 45%, specificity is 74%only 45%, specificity is 74%

Cord blood IgE – 26% sensitive, 74% specificCord blood IgE – 26% sensitive, 74% specific Both fam hx plus cord blood IgE – Sensitivity Both fam hx plus cord blood IgE – Sensitivity

56%56%

Page 33: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Maternal AvoidanceMaternal AvoidanceIgE sensitization to food during IgE sensitization to food during gestationgestation is RARE - < 0.3%is RARE - < 0.3%Maternal avoidance of milk and egg during Maternal avoidance of milk and egg during pregnancy not better than infant avoidance pregnancy not better than infant avoidance – not recommended– not recommendedRisk of maternal malnutritionRisk of maternal malnutritionNo harm in recommending peanut No harm in recommending peanut avoidanceavoidance

Page 34: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Primary PreventionPrimary PreventionBreastfeeding – Inconclusive EvidenceBreastfeeding – Inconclusive Evidence Even if Moms avoid allergenic foods – the Even if Moms avoid allergenic foods – the

results can be transientresults can be transient Food allergens can pass into breast milkFood allergens can pass into breast milk Breastmilk can have immunostimulatory or Breastmilk can have immunostimulatory or

immunosuppressive effects on the infant’s immunosuppressive effects on the infant’s intestineintestine

Cytokine content differs in allergenic and non-Cytokine content differs in allergenic and non-allergenic mothersallergenic mothers

Exclusive breastfeeding can decrease infant Exclusive breastfeeding can decrease infant serum IgE, decrease atopic derm and asthmaserum IgE, decrease atopic derm and asthma

Exclusive breastfeeding during 1Exclusive breastfeeding during 1stst 4-6 mos & 4-6 mos & continuation until 1 year is recommendedcontinuation until 1 year is recommended

Page 35: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Lactation Avoidance DietsLactation Avoidance Diets

Conflicting studiesConflicting studies

Most show it is protective to avoid allergenic Most show it is protective to avoid allergenic foods – less atopic derm and food allergiesfoods – less atopic derm and food allergies

Consider avoiding peanuts and tree nutsConsider avoiding peanuts and tree nuts

Most likely don’t need to avoid egg, cow’s milk Most likely don’t need to avoid egg, cow’s milk and fishand fish

Ensure Ensure 1500 mg/day of elemental calcium1500 mg/day of elemental calcium

Page 36: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Delay solids?Delay solids?

High risk of allergy, delay solids to 6 mos oldHigh risk of allergy, delay solids to 6 mos old Finnish study 1983 – 6 mos BF – 14% rate Finnish study 1983 – 6 mos BF – 14% rate

eczema; Food < 6 mos – 35% eczemaeczema; Food < 6 mos – 35% eczema

Delay cow’s milk or dairy to > 1 yearDelay cow’s milk or dairy to > 1 year

Avoid cow’s milk and soy formulas if possibleAvoid cow’s milk and soy formulas if possible Use hydrolyzed hypoallergenic formulaUse hydrolyzed hypoallergenic formula

Delay eggs until 2 yearsDelay eggs until 2 years

Delay peanuts, nuts, and fish until 3 yearsDelay peanuts, nuts, and fish until 3 years

Page 37: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Anti IgE – Xolair (Omalizumab) Anti IgE – Xolair (Omalizumab) Food challenge with encapsulated peanut Food challenge with encapsulated peanut flour – determined thresholdflour – determined threshold4 SQ injections at 4 week intervals4 SQ injections at 4 week intervals2-4 weeks after had repeat challenge2-4 weeks after had repeat challengeIncrease tolerance fromIncrease tolerance from

½ peanut to 9 peanuts½ peanut to 9 peanutsDose dependent Dose dependent

tolerance*tolerance*25% of group showed 25% of group showed

no improvementno improvement

*NEJM 2003;348:986-93*NEJM 2003;348:986-93

Page 38: Food Allergy. Adverse Food Reactions Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning

Other TherapiesOther Therapies

Traditional Chinese herbs – efficacy in Traditional Chinese herbs – efficacy in murine-model of peanut induced murine-model of peanut induced anaphylaxis – starting human trialsanaphylaxis – starting human trials

Engineered proteins that lack IgE binding Engineered proteins that lack IgE binding sites, engineered chimeric molecules with sites, engineered chimeric molecules with allergen and Fc-gamma, coadministration allergen and Fc-gamma, coadministration of TH-1 promoting adjuvants (CpG and of TH-1 promoting adjuvants (CpG and heat-killed bacteria)heat-killed bacteria)

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SummarySummaryPatient history is very importantPatient history is very importantDetermine IgE vs. non-IgE mediated Determine IgE vs. non-IgE mediated Diagnosis by judicious testing, elimination and Diagnosis by judicious testing, elimination and challengechallengeAvoidance/education/preparation for emergencies Avoidance/education/preparation for emergencies are current therapies are current therapies No conclusive studies indicating that manipulation of No conclusive studies indicating that manipulation of the mother’s diet during pregnancy or lactation or the mother’s diet during pregnancy or lactation or the restriction of allergenic foods from the infant’s the restriction of allergenic foods from the infant’s diet will prevent the development of food allergydiet will prevent the development of food allergyPeriodic re-challenge to monitor tolerance as Periodic re-challenge to monitor tolerance as indicated by history, allergen and level of food indicated by history, allergen and level of food specific IgEspecific IgE

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ReferencesReferences

Sampson HA. Middleton Ch 89 – Adverse Sampson HA. Middleton Ch 89 – Adverse Reactions to FoodsReactions to FoodsSicherer SH, Sampson HA. Mini-primer. Sicherer SH, Sampson HA. Mini-primer. Ch 9. Food Allergy.J Allergy Clin Immunol Ch 9. Food Allergy.J Allergy Clin Immunol 2006; 117:s470-475.2006; 117:s470-475.Sampson HA. Primer. Ch 9. Food Sampson HA. Primer. Ch 9. Food Allergy.J Allergy Clin Immunol 2003; Allergy.J Allergy Clin Immunol 2003; 111:s540-547.111:s540-547.MKSAP – Allergy and Clinical MKSAP – Allergy and Clinical Immunology. Ch 4 – Food Allergy. Pages Immunology. Ch 4 – Food Allergy. Pages 194-208194-208