Food Allergy & Anaphylaxis: Practical Problems in the Real WorldBruce J. Lanser, MDAssistant Professor of PediatricsDirector, National Jewish Health Pediatric Food Allergy ProgramAssociate Director, Pediatric Allergy Fellowship Training ProgramProp

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Disclosures• Advisory Board/Consultant: AImmune Therapeutics (OIT), Hycor and

Allergenis (food allergy diagnostics)• Speaker: AImmune• Research Support: AImmune, DBV (EPIT)• Member: NIH/NIAID sponsored Consortium on Food Allergy Research

(CoFAR)

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Objectives1. Understand the basics of IgE-mediated food allergy2. Be aware of current and future management approaches to food allergy3. Discuss the role for 504 plans, shared management between parents and

schools, and opportunities to decrease the risk for reactions4. Understand the significant psychosocial burden of food allergies including

anxiety and bullying, and techniques to mitigate these burdens

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FOOD ALLERGY INCIDENCE

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Adverse Food Reactions

- Immediate- Oral allergy syndrome- Immediate- Oral allergy syndrome

- Eosinophilic GI disease (EGID)- Eosinophilic esophagitis (EoE)

- Eosinophilic GI disease (EGID)- Eosinophilic esophagitis (EoE)

- Food protein-induced enterocolitis (FPIES)

- Celiac disease

- Food protein-induced enterocolitis (FPIES)

- Celiac disease

IgE-Mediated Non-IgE-MediatedMixed

IMMUNOLOGIC

Other/UndefinedMetabolic

NON-IMMUNOLOGIC

Toxic

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Epidemic Increase in Food Allergy in US

3.4% 3.6% 3.8%4.3%

5.1%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

1997-1999 2000-2002 2003-2005 2006-2008 2009-2011

Food Allergy Prevalence (Reported, NHIS data)

Jackson KD, et al. NCHS data brief, no 121. 2013Prop

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Top 16 Allergens - EU

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Natural History of Food Allergy• Milk, egg, wheat and soy

• Commonly outgrown, 50-80%

• Peanut• 20% outgrow

• Tree nuts• ~10% outgrow

• Fish and Shellfish• Very rarely outgrown

• Other foods• Sesame seed 20-30% ?• ???

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Anaphylaxis• Food is the most common trigger

• Estimates vary from 0.4% to 40% of allergic food reactions resulting in anaphylaxis

• Incidence has increased, but fatalities have not• New York State, 1990-2006- >4-fold increase in hospitalization for anaphylaxis• UK, 1990-2012- doubling of hospitalization for food-induced anaphylaxis

• African American and Hispanic children have significantly higher rates of food-induced anaphylaxis, and more ED visits

• Risk factors for fatal anaphylaxis• Teenagers• Sub-optimal asthma control• Delayed epinephrine

Lin RY, et al. Ann Allergy 2008;101:387‐93.Mahdavinia M, et al. JACI IP 2017;5:352‐7.Motosue MS, et al. Ann Allergy 2017;119:356‐61.Turner PJ, et al. Allergy 2016;71:1241‐55.

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Standard of Care• Unsatisfying!

• Strict avoidance• Education

• Reading labels• Recognizing and treating a reaction• Natural history• Managing special situations

• How to use autoinjectableepinephrine

• Providing Food Allergy Action Plans• Nutritional monitoring

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Treatment• Epinephrine is the only treatment for anaphylaxis and respiratory symptoms

• Antihistamines only treat mild symptoms

• Everyone should carry a twin pack at all times• “No epi, no eating”

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Epinephrine• Hold for 3 seconds (previously 5-10), then massage area

• In small children, hold leg to prevent injury

• Dosing:• Change to full-strength at 25kg based on guidelines (package insert = 15 to 30kg)• AuviQ 0.1mg now available (7.5 to 15kg)

When in doubt…give epi!!!

• Antihistamines will not treat respiratory symptoms!• 2 or more systems, give epi• Hives only = anithistamines• Vomit x1 = OK to watch

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Airborne & Contact Reactions• Airborne reactions are uncommon• Certain foods and situations are more likely to introduce food proteins into the

air• Cooking fish and shellfish• Boiling peanuts or milk• Grains and flour

• Some foods have NO potential to release protein in the air• Peanut butter• Eggs• Baking breads

• Contact reactions are typically mild and self-limited• BUT, kids often put their finders in the nose and mouth!

Perry TT, et al. JACI 2004;113:973‐6.Simonte SJ, et al. JACI 2003;112:180‐2.

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Minimizing Risk• Have a box of special, safe snacks at school• Epi goes everywhere you go…“No Epi, No Eatie”• Consider medical alert bracelet• Before you eat anything, "time out", think about what is going in your mouth• If you can't read the label, you shouldn't eat it• ALWAYS ask about ingredients when not eating at home• "Shoot" expired Injectable epinephrine into an orange for practice• List courtesy of Dr. Allan Bock Prop

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FOOD ALLERGY LABELING

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Reading Labels

• “Precautionary Labeling” is voluntary and unregulated• “May contain” and “processed in a facility” don’t have a standard definition

• All ingredients do not have to be labeled in processed foods• The 8 major allergens MUST be identified on food labels

• Tree nut in US (not EU) includes coconut• Shellfish in US does NOT include mollusks (oyster, clam, scallop)

DunnGalvin A, et al. CEA 2019;49:1191‐2000.Blom WM, et al. JACI IP 2018;142:865‐75.

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Contacting Manufacturers• Ask specific questions about how the product is manufactured

• Are there peanuts in the facility?• Is this product run on the same line as peanut products?• Are the lines cleaned between runs?• How are the lines cleaned?

• Exercise precaution for manufacturers with “canned responses.”• E.g. “We follow FDA guidelines and we use good manufacturing processes…”Prop

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Precautionary Allergen Labeling

• Pele et al, 2007 – peanut contamination • 25% without PAL, 32% with PAL

• Ford et al, 2010 – milk, egg, or peanut• 1.9% without PAL, 5.3% with PAL• Peanut was not detected in any of the products

• Ireland • 11% without PAL, 6.5% with PAL

• 17-65% of products contain PAL

• The absence of PAL does not imply food is safe for consumption for allergic individuals.

Allen KJ, et al. WAO J. 2014;7:1-14.Versluis A, et al. CEA. 2015;45:347-67.

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Balancing Risks

DunnGalvin A, et al. CEA 2019;49:1191‐2000.Blom WM, et al. JACI IP 2018;142:865‐75.

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Sources of Accidental Exposures

Blom WM, et al. JACI IP 2018;142:865‐75.Prop

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Quality of Life (QoL)• Diagnosis of food allergy carries significant medical, nutritional, and psychosocial implications• Formidable task of vigilance with strict food elimination • Providing a safe diet without foregoing proper nutrition• Living with constant stress and fear of accidental exposures• Limitations in daily activities• Impact on school attendance, social relations• Impairment in family activities and relationships

• Social isolation• Worse QoL than those with type I diabetes

Bollinger ME, et al. Ann Allergy Asthma Immunol 2006;96:415‐21.Klinnert MD, et al. Curr All Asthma Rep 2008;8:195‐200.Prop

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Anxiety• Appropriately increased in most families with food allergy

• Some level of anxiety is good• Anxiety increased from

• Reactions from accidental exposures• Anaphylaxis in particular

• Developmental transitions• New information about or changes in risk

• 79% have difficulty going out to eat• 16% completely avoid going out to restaurants• Many change vacation plans• Afraid about eating at school

• Many parents (and children) develop distorted perceptions about the real dangers faced by children with food allergy

Klinnert MD, et al. Curr All Asthma Rep 2008;8:195‐200.Prop

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Bullying• 1/3 of kids with food allergies report having been bullied specifically because

of their food allergies

Shemesh E, et al. Pediatrics 2013;131:e10‐7.Prop

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Bullying• Stop bullying!

• Create a supportive environment• Promote reporting of bullying• www.stopbullying.gov

Shemesh E, et al. Pediatrics 2013;131:e10‐7.Prop

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Managing Anxiety• Be prepared!• Practice scenarios

• Exposure challenges with an allergist

• Behavioral Health Specialist Referral • Counseling and education• Cognitive behavioral therapy• Biofeedback• Guided relaxation

• Self-Directed Therapies• Self-hypnosis• Meditation

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504 PLANS & MORE

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Team Approach

School Staff Family Allergist

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Creating an Environment Where Children Food Allergies Feel Safe• Keep allergens out of the classroom and/or keep classrooms food-free

• Snacks• Craft and science projects• Birthday and holiday parties

• Encourage hand washing for students and staff before and after eating/handling food• Use soap and water!

• Wash all tables and chairs before and after eating• Consider ”allergy friendly” tables*• Every child with a known food allergy should have a written food

allergy/anaphylaxis action plan

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Written Plans• Typically 504 plans in public schools,

similar written plans in private schools• Serves to level the playing field so that

students with food allergies are not excluded, and can SAFELY participate in school activities

• 504 v IEP

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Problem Areas

• Does the student have a “safe space?”• Do they feel isolated at lunch?• Do they have age-appropriate, easy access to emergency medications?• Are they included in activities and parties?• Are other children and staff respectfully aware?• Does the school culture promote:

• Safety• Respect• Acceptance of differences

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More Information• FARE

• www.foodallergy.org

• CDC• www.cdc.gov/healthyyouth/foodallergies• www.cdc.gov/healthyschools/foodallergies

• FACT• www.foodallergyawareness.org

• Department of Education• www.ed.gov

• Allergy Safe Kids• www.allergysafekids.org

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RESEARCHA special thank you to Ashley Kohlhepp, Caroline Bronchick, the NJH CTRC, and our study patients/families!Prop

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Food Allergy Immunotherapy Methods

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Real World Implications

Baumert JL, et al. JACI IP 2018;6:457‐65.e4.Prop

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Updated OFC Work Group Report

Bird JA, et al. JACI IP 2020;8:75‐90e17.Prop

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FOOD ALLERGY: FACT OR FICTION

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Smelling peanut butter can cause an allergic reaction

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Peanuts, tree nuts, fish and shellfish are the only allergens that can cause serious,

life-threatening allergic reactions Prop

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Epinephrine is the only treatment for anaphylaxis

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If you give epinephrine and someone is not having an allergic reaction, they will

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Hand sanitizing gels and wipes remove allergen from hands and surfaces

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Touching an allergen is unlikely to cause a serious allergic reaction

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Airborne allergic reactions can only happen to some severely allergic individuals

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THANK YOU!Donald Leung, Allan Bock, Drew Bird, April Clark, and all my mentors!Prop

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Questions & Discussion

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Food Allergy & Anaphylaxis: Practical Problems in the Real WorldBruce J. Lanser, MDAssistant Professor of PediatricsDirector, National Jewish Health Pediatric Food Allergy ProgramAssociate Director, Pediatric Allergy Fellowship Training ProgramProp

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