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Impact of Food Allergies

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Impact of Food Allergies Faculty Disclosure I have nothing to disclose. Question #1 A 7-year-old boy with A. Intravenous fat an enterocutaneous emulsion fistula develops an B. Amino acid urticarial rash the day solution that he is started on C. Pediatric parenteral nutrition. Multivitamin All of the following solution constituents of his parenteral nutrition D. Dextrose could cause the rash EXCEPT: Question #2: An 18-month-old vegetarian A. Fat girl with presumed milk and B. Vitamin D soy protein allergy is drinking 32 ounces of enriched C. Energy almond milk per day. She D. Zinc also eats rice, wheat, corn, fruits, and vegetables but does not consume any egg or meat products. She does not receive any vitamin or mineral supplementation. You are concerned about her intake of all of the following EXCEPT: Question #3: A 6-year-old Asian boy is seen A. Assessment of growth and by a dietitian for follow-up nutrient intake nutritional assessment and B. Suggesting an age- education. His parents report appropriate beverage he is allergic to milk, soy, and C. Recommending follow-up peanuts. He has a history of with allergist as patient is anaphylaxis while eating tolerating milk and soy peanut butter a year ago. His D. Suggesting food current intake includes tofu stir- challenge of peanut fry and milk chocolate candy butter at home bars. Parents report he eats these foods at least once a week without any problems. He does not drink a milk substitute. All of the following must be done or considered at this visit EXCEPT: Question #4 A 6-month-old breastfed A. This consistent with IgE- infant has significant mediated anaphylaxis. vomiting and diarrhea B. This is most likely food within hours of being given protein-induced a bottle of cow’s milk enterocolitis syndrome formula. His mother reports that this has happened C. Cow’s milk protein must each time he has been fed be eliminated from the the formula. She denies any child’s diet skin rashes. A serum lab for D. In addition to IgE directed against cow’s breastfeeding, a protein milk protein is negative. All hydrolysate formula of the following are true may be appropriate about this child EXCEPT: Learning Objectives • Improve understanding of nutrition management of children with multiple food allergies • Describe the nutrition assessment of children with food allergies • Understand the food and non-food issues that may impact the provision of nutrition support in children with food allergy Food Allergy – Concern? • Increased public health concern in Western World • Greater problem in children than in adults • Associated with poorer nutrition outcomes What’s the story? • “Telling Food Allergies From False Alarms” (The New York Times) • “Is Your Kid Truly Allergic? Tests Add to Food Confusion” (The Wall Street Journal) • “Adverse Reactions to Food: Allergies & Intolerance” (Digestive Diseases) • “’Allergic Girl’ teaches how to eat out with allergies” (CNN.com) • “This allergies hysteria is just nuts” (British Medical Journal) • “Children at risk in food roulette” (ChicagoTribune.com) • “Fear and Allergies in the Lunchroom” (Newsweek) • “Food Allergen’s Attack” (Food Service Director) • “Food Allergies Take a Toll on Families and Finances” (The New York Times) Food Allergens Identified as a protein or glycoprotein Food Allergy May be more or less common Resist depending on denaturation the society or by heat or acid ethnicity What is Food Allergy? • Two important points: – An immune response • Reproducible response to food protein. • Positive skin prick test or high blood test (serum specific IgE level) to the food can not diagnose food allergy without a reaction or previous exposure to food – Different from a food intolerance • Example: Lactose intolerance – GI symptoms from milk sugar (not protein) – Not an immune response – Often can tolerate some milk in some forms or different amounts (such as yogurt or cheese) • Other intolerances can include; reactions to preservatives (MSG), alcohol, caffeine, theobromine in chocolate. Defining Food Allergy (Immunologic Reaction to Food) IgE Mediated Syndromes Mixed IgE and Non-IgE Non-IgE Mediated Mediated Syndromes Syndromes Oral allergy syndrome Eosinophilic Esophagitis Protein-induced enterocolitis Anaphylaxis Eosinophilic gastritis Protein-induced enteropathy Urticaria Eosinophilic gastroenteritis Food protein-induced enterocolitis syndrome Angioedema Atopic dermatitis Dermatitis herpetiformis, celiac diease Food Allergy • 15 million Americans have food allergies • 3 million are school aged • Between 1997 & 2007 prevalence of childhood food allergy increased by 18% • 150 reported deaths each year from anaphylaxis related to food allergies in the United States 2008 National Center for Health Statistics assessment The Food Allergy & Anaphylaxis Network; Food Allergy Facts and Statistics for the U.S. 2012 Food Allergies in the United States • Prevalence of food allergy in general population is 1-2% • Nearly 3 million children have food allergies – 8% of all children – Young children affected most • Food allergies may be resolving more slowly than previous decades – Many children still allergic beyond age 5 years – Some persist throughout life Major Food Allergens • Egg • Milk • Peanut • Tree nut • Fish • Shellfish • Soy • Wheat Table of Cross Reactive Foods Sicherer SH: J Allergy Clin Immunol, 2001 Evaluation of Suspected Food Reactions ALLERGY TESTING How are Food Allergies Diagnosed? • History of reactions at home – Allergy testing must match history of reactions – 50-90% of supposed food allergies are not accurate • Blood tests – Specific Serum IgE testing (sIgE) • Skin tests – Scratch tests Diagnosis • Do not test for foods a child has not been exposed to – For example, do not test strawberry, beef or broccoli for a 6 month old that has never eaten these foods and is not breastfed • Do not test for foods the patient tolerates Test Results – What do they mean? • Skin tests and serum specific IgE tests can both give false positive results – About 50% • Example – Positive serum specific IgE test for milk – The child drinks milk with every meal – What do these test results mean? • Broad screening should NOT be done without history of reaction because of the high rate of false positives Skin Prick Testing Photos with patient permission Test Results • Negative skin test or serum specific IgE means the IgE antibody is not present (>95% specific) • Positive skin test or specific IgE – Indicates that the IgE antibody is present – Does NOT necessarily mean that patient will have a reaction – 90% sensitive – 50% specific – Larger skin test size/higher IgE level correlates with likelihood of reaction but does not tell you how severe the reaction will be Did I eat something while I was pregnant that caused my child’s allergy? I craved peanuts when I was pregnant… PREVENTION Prevention of Food Allergies • Avoiding foods in pregnancy does not seem to prevent allergy, eczema, or asthma • Avoiding or delaying foods in infancy does not prevent allergy for infants who are not high risk American Academy of Pediatrics Clinical Report January 2008; www.aap.org Prevention of Food Allergies • High-risk children - parent or siblings with food allergy – Breast milk or hyrdolyzed infant formula until 4 months of age – Soy formula likely doesn’t prevent allergies – Delay introduction of solids until 4—6 months of age • No reason to delay introduction past this time • Okay to include foods that are considered to be highly allergic such as fish, eggs and foods containing peanut protein. American Academy of Pediatrics Clinical Report January 2008; www.aap.org Natural History of Food Allergy • Most children with food allergies will eventually tolerate milk, egg, soy and wheat • The age that most children outgrow the allergy varies by food • If initial serum specific IgE (sIgE) level for a food is high, they are less likely to outgrow the allergy Hourihane, 1998; Sampson, 2004; Boyce, 2010; Wasserman, 2011 Food Challenge • Performed to determine tolerance • Conducted in an allergist’s office where emergency equipment is available • Skin prick test and serum specific IgE test results meet criteria to qualify for a challenge • Patient is fed the food in increasing amounts watching for a reaction Fatalities in Anaphylaxis • Food anaphylaxis is the leading cause of anaphylaxis treated in emergency department – 30,000 cases per year – 150—200 deaths per year • Peanut, tree nut and seafood account for most of these reactions • Cannot be predicted by past reactions Sampson et. al. Pediatrics 2003 111:1601-8 Fatal Food-Induced Anaphylaxis • 32 cases of fatal anaphylaxis reviewed • Most were teens or young adults • Peanuts and tree nuts caused >90% of reactions • 2/3 of the patients had asthma • Most did not have epinephrine available or did not use it Bock SA, et al. Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol 2001;107:191–193 Key Point: Benadryl will NOT block anaphylaxis • A history of a mild reaction does not mean that future reactions will be mild • Consider an Epi Pen for all at risk of anaphylaxis • It is never wrong to use the Epi Pen • When you are considering using the Epi Pen….. use it! Sampson, H., et. al., 2007 MANAGEMENT Management It Takes A TEAM • No cure for food allergies • Strict avoidance • May lead to nutrition consequence • Careful diagnosis of non-IgE mediated allergy • Future treatment – Anti-IgE monoclonal antibody – Allergen immunotherapy • 3 forms under investigation: oral, sublingual and epicutaneous Other Related Diagnosis • Cow’s Milk-Protein
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