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Allergy guidelines insert_Layout 1 9/26/11 1:36 PM Page 1

What you need to know about the new guidelines for the diagnosis and management of in the U.S.

V OLUME 126, N O . 6 D ECEMBER 2010 • Tests for food-specific IgE are recom- Overview www.jacionline.org • The Guidelines, sponsored by the NIH Supplement to mended to assist in diagnosis, but should (NIAID), are based upon expert opinion THE JOURNAL OF not be relied upon as a sole means to di- Allergy ANDClinical and a comprehensive literature review. agnose . The / AAP had input on the document.1,2 exam are recommended to aid in diag- nosis. A medically monitored feeding

Guidelines for the Diagnosis and Management Definitions of Food Allergy in the United States: Report of the (food challenge) is considered the most NIAID-Sponsored Expert Panel • Food allergy was defined as an adverse definitive test for food allergy. health effect arising from a specific im- • Food-specific IgE testing has numerous mune response. limitations; positive tests are not intrin- • Food result in IgE-mediated sically diagnostic and reactions some- immediate reactions (e.g., ) OFFICIAL JOURNAL OF times occur with negative tests. These and several chronic (e.g., ente- Supported by the Food Allergy Initiative issues are also reviewed in an AAP Clini- rocolitis syndromes, eosinophilic esopha - cal Report.3 Testing “food panels” with- gitis, etc), in which IgE may not an important role. out considering history is often mis - leading. Tests selected to evaluate food allergy should be and Natural History based on the patient’s medical history and not comprise • Food allergy is more common in children than adults, large general panels of food . but many allergies eventually resolve. • In the context of moderate to severe atopic , • Among the most common food , children less than 5 years old should be considered for , , and soy allergies often resolve in - food allergy evaluation for milk, egg, , wheat, and hood; peanut, tree , and shellfish allergies can re- soy, if at least 1 of the following conditions is met: solve, but are more likely to persist. 1) The child has persistent AD in spite of optimized • prevalence has increased during recent management and topical , or decades and now affects 1-2% of young children. 2) the child has a reliable history of an immediate reaction after of a specific food. Risks Care should be taken to ensure these children are clin- • Fatal food allergic reactions are usually caused by peanut, ically allergic to a food prior to removing it completely tree nuts and seafood, but have also occurred from milk, from their because restrictive diets may be harmful. egg, and other . • Several tests are not recommended, including food- • Fatalities have been associated with: age (teenagers and IgG/IgG4, , provocation neutraliza- young adults), delayed treatment with , and tion, hair analysis, and electrodermal testing. co-morbid . • Severity of future allergic reactions is not accurately pre- Prevention dicted by past history or allergy test results. • The recommendations for diet are in agreement with the 2008 AAP Clinical Report on this topic.4 Breast- Diagnosis feeding is encouraged for all, if not exclusively breast- • Food allergy should be suspected when typical symptoms feeding, hydrolyzed infant formulas are suggested for (e.g., urticaria, , wheezing, mouth , , “at risk” (at least 1 first-degree relative, or nausea/, anaphylaxis, etc) occur within minutes sibling with allergic ). Complementary foods, in- to hours of ingesting a food. Food allergy rarely causes cluding potential allergens, are not restricted after 4-6 isolated chronic respiratory symptoms, namely those of months of age (not applicable for infants experiencing and asthma. allergic reactions). Allergy guidelines insert_Layout 1 9/26/11 1:36 PM Page 2

Management Further Information • Education about food avoidance is key to prevent This document is only a brief outline of the topics covered by the reactions. This includes information about label reading Guidelines, prepared as a joint effort of the Section on Allergy and and cross-contact of allergens (unintended contamina- Immunology of the AAP and the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma and tion during food preparation). Immunology. The reader is encouraged to refer to the original sources • Nutritional evaluation and growth of for additional information. The Guidelines present a number of re- children with food allergy is recommended. sources for additional information about food allergies. AAP and se- lected resources are listed here. • It is acknowledged that having a food allergy disrupts • AAP Section on Allergy and Immunology quality of life. www.aap.org/sections/allergy • Advice about vaccination for persons with egg • American Academy of Allergy, Asthma & Immunology allergy is reviewed, with more options for administration (AAAAI) www.aaaai.org/ to those with . • American College of Allergy, Asthma and Immunology • Management of anaphylaxis emphasizes prompt (ACAAI) www.acaai.org/ administration of epinephrine, observation for 4-6 hours • Asthma and Allergy Foundation of America (AAFA) www.aafa.org/ or longer after treatment, education of the on avoidance, early recognition, treatment, medical iden- • Consortium of Food allergy Research, Food Allergy Education Program http://web.emmes.com/study/cofar/ tification jewelry, and follow up with a primary health EducationProgram.htm; care provider and consideration for consultation with • Food Allergy & Anaphylaxis Network (FAAN) www.foodal- an allergist-immunologist. lergy.org/; • Prescription of epinephrine autoinjectors and patient • Food Allergy Initiative (FAI) www.faiusa.org/ education advice substantially follows the 2007 AAP • Kids With Food Allergies (KFA) Clinical Report on this topic,5 including having 2 doses www.kidswithfoodallergies.org/; available, switching from 0.15 to 0.3 mg fixed-dose au- • National Institute of Allergy and Infectious Diseases (NIAID) toinjectors at approximately 25 kg (55 lbs) in context of www.niaid.nih.gov/ patient-specific circumstances, having a written emer- REFERENCES: gency plan, and providing supporting educational ma- 1. Boyce JA, Assa’ad A, Burks AW, Jones SM, Sampson HA, Wood RA et al. terial. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin • When multiple-food is undertaken for Immunol 2010; 126(6):1105-18. suspected food-exacerbated , and 2. Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa’ad A, et al. eczema subsequently improves, it is essential to perform NIAID-Sponsored 2010 Guidelines for Managing Food Allergy: Applications in a systematic reintroduction of the eliminated foods. This the Pediatric Population. . 2011;128(5). 3. Sicherer SH, Wood RA. Allergy Testing in Childhood: Using -Specific will help to minimize avoidance of non-allergenic foods, IgE Tests. Pediatr. In press. and confirm which foods are clinically relevant. 4. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal di- • Suggests consideration for a referral to an allergist/im- etary restriction, , timing of introduction of complementary foods, munologist for testing, diagnosis and ongoing manage- and hydrolyzed formulas. Pediatrics 2008; 121(1):183-91. ment. 5. Sicherer SH, Simons FE. Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics 2007; 119(3):638-46. • The Guidelines do not provide specific advice for school 6. Sicherer SH, Mahr TA; The Section on Allergy and Immunology. Management management, but these issues were covered in a recent of Food Allergy in the SChool Setting. Pediatrics 2010; Dec; 126(6):1232-1239. AAP Clinical Report.6

Distribution and funding made possible by the AAP Section On Allergy and Immunology.