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Home , Anaphylaxis, Angioedema, Food allergy, Food intolerance, Food processing

National Institutesof Health U.S. DEPARTMENT OFHEALTH AND HUMANSERVICES Diseases Infectious and of Institute National Summary and Guidelines Allergy

Management

for for

in

Patients, Patients, the

for

United

the

Families, Families,

Diagnosis of

States

and and

Caregivers Caregivers

NIAID

National Institute of Allergy and Infectious Diseases

Guidelines for the Diagnosis and Management of in the United States Summary for Patients, Families, and Caregivers

U.S. DEPARTMENT OF HEALTH AND National Institutes of Health National Institute of Allergy and Infectious Diseases NIH Publication No. 11-7699 May 2011 www.niaid.nih.gov

30 29 25 19 9 6 4

* Note:Words inbluethroughoutthetextaredefinedglossary. Glossary* Sample AnaphylaxisEmergencyActionPlan Caused byFood Diagnosis andManagementofAnaphylaxis Prevention ofFoodAllergy Management ofNonacuteAllergicReactionsand Diagnosis ofFoodAllergy Food Allergy, Prevalence,andAssociatedDisorders Introduction Contents CONTENTS

3 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 4 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES how tocarefortheirpatientswithfoodallergy. provide healthcareprofessionalswiththemostup-to-dateclinicaladviceon United States:ReportoftheNIAID-SponsoredExpertPanel werewrittento The GuidelinesfortheDiagnosisandManagementofFood Allergy inthe be severe, leadingtoalife-threateningallergicreactioncalledanaphylaxis. can beaworry. Although allergicreactionstofoodcanbemild, theyalsomay harm us. Butforpeoplewhoareallergictooneormorefoods, everymouthful Most ofuseatwithoutathoughtthatsomethingsoessentialtolifemightalso Introduction INTRODUCTION foodallergy/clinical. NIAID’s foodallergyguidelines Web site athttp://www.niaid.nih.gov/topics/ If youwanttoreadmoreabouthowtheGuidelines weredeveloped, visit responsibility tomakedecisionsappropriateyour circumstances. families andcaregivers, andthepublic. They donotoverrideyour doctor’s clinical practiceandtohelpdevelopeducationalmaterials forpatients, their document of anygovernment agency. They areintendedasaresourcetoguide What else you should know: managing foodallergy. families, andcaregiversunderstandwhat theGuidelinessayabout appropriate decisionsaboutpatientcare;however, itisvitalthatpatients, The GuidelinesareintendedtohelpU.S. healthcareprofessionalsmake and evaluationofrecentscientificpublicationsaboutfoodallergy. variety ofclinicalbackgroundsdevelopedtheGuidelinesbasedonareview federal agencies, andpatientadvocacy groups. A panelofexpertsfroma National InstitutesofHealth, worked with34professionalorganizations, National Instituteof Allergy andInfectious Diseases(NIAID), partofthe The Guidelinesaretheculminationofa2-yeareffortinwhich How were the Guidelines developed?

The Guidelines are not an official regulatory

• • follows: “suggests.” These wordsconveythestrengthofguideline, definedas There are43guidelines, andeachincludes theword “recommends” or experience abetterqualityoflife. caregivers withtheknowledgetheyneedtomanagedisorderand, inturn, allergy. We hopethatthisinformationwillempowerpatients, families, and and providesastartingpointforpatient-doctorconversationsaboutfood This bookletsummarizesthemostimportantinformationfromGuidelines What does this booklet tell you? diagnose andmanageseverelife-threateningallergicreactionstofood. recommendations onhowtodiagnoseandmanagefoodallergy, andwaysto The Guidelinesincludedefinitionsoffoodallergyandrelateddisorders, What do the Guidelines tell your doctor? handling). health policyissues(forexample, lawsaboutfoodprocessingor settings (forexample, inschoolsandrestaurants)ortherelatedpublic the managementofpeoplewithfoodallergyoutsideclinicalcare clinical guidelinesforceliacdisease. The Guidelinesalsodonotaddress The Guidelinesdonotdiscussceliacdiseasebecausethereareexisting What the Guidelines do not do the lackofstrongevidencetosupportarecommendation. against aparticularcourseofaction. The reasonforthiswasusually Suggest isusedwhentheexpertpanelrecommendedweaklyforor or againstaparticularcourseofaction. Recommend isusedwhentheexpertpanelstronglyrecommendedfor

INTRODUCTION

5 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 6 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES Associated Disorders Food Allergy, Prevalence,and DISORDERS ASSOCIATED AND PREVALENCE, ALLERGY, FOOD are missingtheenzymethat breaksdownlactose, asugarfound inmilk. involve theimmunesystem. Forexample, ifyouare lactoseintolerant, you Food intolerancesareadverse healtheffectscausedbyfoods. They donot reaction, youhaveoutgrownthefoodallergy. If youcanconsistentlytolerateafoodthatoncecaused youtohaveanallergic have symptomsoffoodallergy. a specificIgE(sIgE)antibodytothatfoodallergen, butyoumayornot If youaresensitizedtoafoodallergen, itmeansthatyourbodyhasmade • • your immunesystem. These immunesystemchangesfallintotwocategories: “Allergy” and “allergic disease” refertoconditionsthatinvolvechanges depending onhowtheyareprocessed. soy, corn, , andsesame, mayornotbeallergenic (causingallergy), vegetables, causeallergicreactionsonly wheneatenraw. Foodoils, suchas they havebeencookedordigested. Some , mostoftenfromfruitsand What elseyou shouldknow: Mostfoodallergenscausereactionsevenafter a foodallergen, areactionoccursthat causesthesymptomsoffoodallergy. ) thatarerecognizedbyimmunecells. When animmunecellbindsto Food allergensarethepartsoffoodoringredientswithin(usually response thatoccursreproduciblyonexposuretoagivenfood. A foodallergyisanadversehealtheffectarisingfromaspecificimmune What is food allergy? IgE withtheimmunesystem, buttheinteractiondoesnotinvolvean Non-IgE-mediated—the symptomsaretheresultofinteraction which isthoughttoplayamajorroleinallergicreactions interaction betweentheallergenandatypeofantibodyknownasIgE, (IgE)mediated—thesymptomsaretheresultof

• • • • • • provided below: Prevalence ratesintheUnitedStatesforsomeofthesefoodallergensare tree nuts, soy, , , andcrustaceanshellfish. There areeightmajorfoodallergensintheUnitedStates—, egg, peanut, 4 percentofchildrenaged5to17yearsandadultsintheUnitedStates. estimated thatfoodallergyaffects5percentofchildrenundertheageand A 2007surveyconductedbytheCentersforDiseaseControlandPrevention How common is food allergy? (EoE), or exercise-induced . If someonehasfoodallergy, heorsheismorelikelytohaveasthma, What other conditions can occur with food allergy? to persist. Food allergyalsocanbegininadulthood. Late-developingfoodallergytends is oftenassociatedwithoutgrowingtheallergy. food allergy, islesslikelytooutgrowtheallergy. A decreaseinsIgE life. A childwithahighinitial levelofsIgE, alongwithclinical symptomsof For manychildren, sIgEantibodiescanbedetectedwithinthefirst2yearsof may occuraslatetheteenageyears. children outgrowpeanutandtreenutsallergy. Outgrowingachildhoodallergy Most childreneventuallyoutgrowmilk, egg, soy, andwheatallergy. Fewer Can food allergy be outgrown? young children obtained outsidetheUnitedStates, this rateislikelytobe1–2percentfor Milk andegg:noreliabledataavailablefromU.S. studies, butbasedondata All :0.6percentinchildrenand2.8adults and 2.5percentinadults Crustacean (crab, crayfish, lobster, ):0.5percentinchildren Fish: 0.2percentinchildrenand0.5adults Tree nuts:0.4–0.5percent Peanut: 0.6percent

FOOD ALLERGY, PREVALENCE, AND ASSOCIATED DISORDERS ASSOCIATED AND PREVALENCE, ALLERGY, FOOD

eczema,

7 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 8 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES have . You aremorelikelytohaveasevereallergicreactionfoodifyoualso a futureallergicreactionwillbe. severity ofyourpreviousreactions. Noavailabletestscanpredicthowsevere You cannottellhowsevereyournextallergicreactionwillbebasedonthe processed. including howmuchyouateandwhetherthefoodwascooked, raw, or The severityofallergicreactionstofoodsisbasedonmanydifferentfactors, What are risk factors for severe allergic reactions to ? DISORDERS ASSOCIATED AND PREVALENCE, ALLERGY, FOOD

is EoE. are notcloselyassociatedwitheatingthefood. An exampleofsuchadisorder the GItract. Disorderscausedbythesereactionsdonotgetbetterquicklyand Reactions thatarebothIgE-mediatedandnon-IgE-mediated generallyinvolve milk oregg, isextensivelyheatedonthestovetoporbakedinoven. after exposureifaverysmallamountofthefood iseatenorifthefood, suchas immediately aftereatingthefood. However, anallergicreactionmaynotoccur and adults. The symptomsofanIgE-mediatedfoodallergyalmostalwaysoccur shellfish) accountforthevastmajorityofIgE-mediatedreactionsinteenagers in youngchildren, whereaspeanut, treenuts, andseafood(fishcrustacean Milk, egg, andpeanutaccountforthevastmajorityofIgE-mediatedreactions type ofreactionsoheorshecanselectthecorrectdiagnostictest(s). non-IgE-mediated, orboth. Your healthcareprofessionalneedstoidentifythe What elseyou shouldknow: Food-allergicreactionsmaybeIgE-mediated, • • • • diagnosis offoodallergy Guideline 1recommendsthatyourhealthcareprofessionalshouldconsiderthe When should your healthcare professional suspect food allergy? Diagnosis ofFoodAllergy enterocolitis, enteropathy, orallergicproctocolitis. In aninfantorchilddiagnosedwithmoderatetosevereeczema, EoE, If youhavebeendiagnosedwithEoE. one occasion. Seetable A foralistofallergicsymptomscausedbyfood. hours aftereatingfoodand/oraspecificonmorethan If youareexperiencingacombinationofsymptomswithinminutesto and/or gastrointestinal(GI)tract). involves morethanonebodysystem(forexample, skinandrespiratorytract If youareexperiencinganaphylaxis, asevereallergicreactiontofoodthat

DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS

9 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 10 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS GI, gastrointestinal. Affected part of the body TABLE A. Symptoms of allergic reactions caused by food Other Cardiovascular GI (lower) GI (oral) Lower respiratory Upper respiratory Eyes Sense of“impendingdoom” Uterine contractions Loss ofconsciousness Fainting Dizziness Low bloodpressure Rapid heartbeat(occasionally Reflux Colicky abdominalpain Itching inthemouth Swelling ofthelips,,or Visible signsofshortness Wheezing Shortness ofbreath Chest tightness Dry cough hoarseness Swelling ofthevoicebox Sneezing Runny nose Itching Swelling aroundeyes Redness Tearing Itching Swelling beneaththeskin Measles-like redbumps Itching Redness slow heartbeatinanaphylaxis) palate breath Immediate symptoms — — Bloody stool,irritability, andfood Same asimmediatesymptoms — Wheezing Shortness ofbreath Cough — Same asimmediatesymptoms similartoeczemaandflushing Same asimmediatesymptoms children) refusal withweightloss(young plus plus

Delayed symptoms confirmed byadiagnosis fromahealthcareprofessional. Guideline 3recommendsthatself-reportsofpresumedfoodallergy mustbe • • • • • • • • • Your healthcareprofessionalshouldaskthefollowingquestions: • • however, thesealonearenotsufficienttodiagnosethedisorder. history andphysicalexaminationtohelpinthediagnosisoffoodallergy; Guideline 2recommendsthatyourhealthcareprofessionaluseamedical and physical examination examination, andappropriateteststodiagnoseIgE-mediatedfoodallergy. Your healthcareprofessionalshoulduseamedicalhistory, physical food allergy? How should your healthcare professional diagnose IgE-mediated What treatmentdidyoureceive, andhowlongdidthesymptomslast? Have youhadthesesymptomsotherthanafterbeing exposedtothefood? nonsteroidal anti-inflammatorydrugs? Were otherfactorsinvolved, suchasexercise, alcohol, oruseofaspirin Have youevereatenthefoodwithoutthesesymptoms occurring? How longafteryouwereexposedtothefooddidyoursymptomsoccur? Was thefoodcookedonstovetop, bakedintheoven, orraw? How muchofthefooddidyoueatwhensymptomsoccurred? more thanonce? What foodcausesyoursymptoms, and hasthisfoodcausedthesesymptoms What areyoursymptoms? reaction oradisorderthatisassociatedwithfoodallergy. A physicalexaminationmayrevealsignsthatareconsistentwithanallergic reaction causedbyfoodandsuggestswhichfood(s)maybeinvolved. A detailedmedicalhistoryoftenprovidesevidenceforthetypeofallergic

DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS

11 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 12 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES can affectyournutritionandqualityoflife. food allergyisunreliableandcanleadyoutoavoidfoodsunnecessarily. This people havefoodallergy(asdistinctfromintolerance). Self-reportingof However, whenconfirmedbyahealthcareprofessional, onlyabout1in28 Why thisisimportant: ALLERGY FOOD OF DIAGNOSIS diagnosing foodallergyinvolvingIgE. Table Bsummarizesthevalueofvarioustestsinidentifyingallergensand clinical symptoms. to diagnosefoodallergy. You donothavefoodallergyunlessyoualso have IgE antibodiestofoodallergens. Blood andskintestsalonecannotbeused causing yourreaction. The resultsofthesetestsonlyshowthatyouproduce allergy, therearebloodandskinteststhatcanidentifythefoodsmaybe If yourhealthcareprofessionalsuspectsthatyouhaveanIgE-basedfood Tests to identify foods causing your allergic reaction involving IgE Test Oral foodchallenge Food eliminationdiet patchtest puncture test,sIgEand Combination ofskinprick/ Atopy patchtest serum Allergen-specific IgEinthe Total serumIgE Intradermal testing Skin prick/puncturetest IgE involving allergy food diagnose and allergens food identify to Tests B. TABLE

As manyas1in3peoplethinktheyhavefoodallergy.

(but testposesriskofadversereactions) (but testposesriskofadversereactions) skin prick/puncturetestalone) (but noadvantageover Can it identify a food allergen? Yes Yes Yes Yes Yes Yes No No

Can it diagnose food allergy? Probably Yes No No No No No No

• • • • • • What elseyou shouldknow: of foodextractjustbelowthesurfaceskinonyourlowerarmorback. With anSPT, yourhealthcareprofessionalusesaneedletoplacetinyamount mediated foodallergy. puncture test(SPT)toidentifythefood(s)thatmaybecausingIgE- Guideline 4recommendsthatyourhealthcareprofessionaluseaskinprick/ Skin prick/puncturetest total serumIgE levelsissensitiveorspecific enoughtodiagnose foodallergy. Why notuseit? blood sample). diagnosis basedonthetotal amountofIgEantibodiesintheserum(from a Guideline 6recommendsthatyourhealthcareprofessional not makea Total serumIgE likely to have an adverse reaction to an intradermal test, compared with an SPT. testing is more useful than an SPT to diagnose food allergy. You also are more Why not use it? the skin. An intradermaltestisperformedbyinjectingasmall amountofallergeninto testing todiagnosefoodallergy. Guideline 5recommendsthatyourhealthcareprofessionalnotuseintradermal Intradermal test do occur. Occasionally, evenwhenthefoodallergy involvesIgE, negativeSPTresults positive resultshowsthatyouhavemadeIgEantibodiestothefood. A positiveSPTresultdoesnotmeanthatyouareallergictothefood. A and flare. ThisoccurswhenafoodallergenreactswithitsIgEantibody. A positiveSPTresultisaraisedbumpwithrednessaroundit, calledawheal The resultsofanSPTusuallyappearwithin30minutes. SPTs canidentifyfoodsagainstwhichyouhavemadeIgEantibodies. SPTs aresafe.

There is not enough clinical evidence to show that intradermal There isnotenoughclinical evidencetoshowthatmeasuring

DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS

13 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 14 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES • • • • What elseyou shouldknow: food allergy. However, thesetestsbythemselvesdonotdiagnosefoodallergy. serum (fromabloodsample)toidentifyfoodsthatmayberesponsibleforthe Guideline 7recommendsthatyourhealthcareprofessionaltestforsIgEinthe Allergen-specific IgEintheserum ALLERGY FOOD OF DIAGNOSIS IgE-mediated foodallergy disorders. foods responsibleforsome non-IgE-mediatedandsomemixedIgE-non - from yourdiettohelpdiagnose foodallergy. Foodelimination mayidentify Guideline 10suggeststhatyourhealthcare professionaleliminatespecificfoods Food eliminationdiet tests alone. SPTs, sIgEtests, and APTs incombinationisbetterthanusingSPTs orsIgE Why notuseit? of SPTs, sIgEtests, and APTs todiagnosefoodallergy. Guideline 9suggeststhatyourhealthcareprofessional not usethecombination Use ofskinprick/puncturetests,sIgEandatopypatch testsincombination useful indeterminingwhetheryouhavenoncontactfoodallergy. Why notuseit? that releasesasmallamountoffoodallergenintothetissuesbeneathskin. An APT isperformedbyplacingasticky patchontheskinofupperback test (APT)toassessnoncontactfood allergy. Guideline 8suggeststhatyourhealthcareprofessionalnotuseanatopypatch Atopy patchtest involving IgE. Undetectable sIgElevelsoccasionallyoccurinpeoplewithfoodallergy The resultsofsIgEtestingandSPTs donotalwaysmatchup. the skin)orwhenyouneedtotakeantihistamines. SPTs cannotbedonewhenyouhaveextensivedermatitis(inflammationof Serum testingcanbeespeciallyusefulifSPTs cannotbedone. Forexample, Measuring sIgElevelscanbeusefulinidentifyingpossiblefoodallergens.

There isnotenoughclinicalevidencetoshowthat using There isnotenoughclinicalevidencetoshowthat APTs are

• • • There arethreetypesoforalfoodchallengetests: • • • • An oralfoodchallengetestincludesthefollowingsteps: treat potentialsevereallergicreactions. and atamedicalfacilitythathasappropriatemedicinesdevicesto performed byahealthcareprofessionaltrainedinhowtoconductthistest Note: Becauseanoralfoodchallengetestalwayscarriesarisk, itmustbe food challengetesttodiagnoseallergy. Guideline 11recommendsthatyourhealthcareprofessionalusetheoral Oral foodchallengetest results ofafoodeliminationdietmayprovidediagnosis. For non-IgE-mediated food allergy disorders, your medical history and the professional shouldperformadditionalteststoconfirmthediagnosis. eliminate a food from your , you may have food allergy. Your healthcare What elseyou shouldknow: Ifyoursymptomsdisappearwhenyou healthcare professionalknow whetherafoodallergenisreceived. under certaincircumstances. Inthistest, boththe patientandthe An open-foodchallenge test maybesufficienttodiagnosefoodallergy patient doesnot. healthcare professionalknowswhatthepatientis receiving, butthe A single-blindfoodchallengeisthenextbestoption. Inthistest, the the patientreceives. Neither thepatientnorhealthcareprofessional knowswhichone doses ofthesuspectedfoodallergenoraharmless substance(placebo). considered thebestone. Inthistest, thepatientreceivesincreasing A double-blindplacebo-controlledfoodchallenge (DBPCFC)testis You arewatchedtoseewhetherareactionoccurs. You swalloweachdose. increased duringthechallenge. Initially, thedoseoffoodisverysmall, buttheamountisgradually triggering anallergicreaction. You aregivendosesofvariousfoods, someofwhicharesuspected

DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS

15 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 16 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES alternative. professional mayconsiderusingasingle-blindoropen-foodchallengeasan food allergy, butitcanbeexpensiveandinconvenient. Your healthcare What else you should know: food allergyisconfirmed. consistent with your medical history and laboratory tests, then a diagnosis of be ruledout. Ifthechallengeresultsinsymptomsandtheseare If anoralfoodchallengetestresultsinnosymptoms, thenfoodallergycan ALLERGY FOOD OF DIAGNOSIS allergy thatdoesnotinvolve IgE. Table Cliststeststhatyourhealthcareprofessional shouldusetoevaluatefood • • • • • not involveIgE: The followingareexamplesofdisordersassociatedwithfoodallergythatdo between afoodallergythatinvolvesIgEandonedoesnot. history andphysicalexaminationalonemaynothelpyourdoctordistinguish The diagnosisofnon-IgE-mediatedfoodallergycanbechallenging. A medical food allergy? How should your healthcare professional diagnose non-IgE-mediated for alistofthesetests. See thefullGuidelinesathttp://www.niaid.nih.gov/topics/foodallergy/clinical not recommendedintheGuidelinestodiagnosefoodallergyinvolvingIgE. Guideline 12recommendsthatyourhealthcareprofessionalavoidusingtests Nonstandardized andunproventests Systemic contactdermatitis Allergic contactdermatitis(ACD) Food -inducedallergicproctocolitis(AP) Food protein-inducedenterocolitissyndrome(FPIES) mixture ofIgE-andnon-IgE-mediated Eosinophilic GIdiseases(EGIDs), but oneexceptionisEoE, whichcanbea

The DBPCFC is the most specific test for diagnosing

should beretested toconfirmthatFPIES hasbeenoutgrown. What elseyou should know: FPIESoftenlastsonlya few years. A patient symptoms whileavoiding thefoodcanconfirmdiagnosis. low bloodpressureormultiple reactionstothesamefood, the absenceof patient isaninfantorchildandthemedicalhistory includesepisodesof history andanoralfoodchallengetesttodiagnose FPIES. However, ifthe Guideline 14recommendsthatyourhealthcareprofessionaluse amedical Food protein-induced enterocolitis syndrome localized or widespread. EoE is one type of EGID. part of the GI tract is involved and whether the accumulation of is in a from the GI tract. The symptoms of these disorders depend on which diagnosis of an EGID after finding high levels of immune cells called eosinophils What elseyou shouldknow: Usually, ahealthcareprofessionalmakes a tests inthediagnosisofotherEGIDshasnotbeenestablished. sIgE tests, and APTs toidentifyfoodsassociatedwithEoE. The roleofthese Guideline 13suggeststhatyourhealthcareprofessionalconsiderusingSPTs, Eosinophilic gastrointestinal diseases EGID, eosinophilicgastrointestinaldisease;sIgE,specificIgE.

Systemic contactdermatitis Allergic contactdermatitis proctocolitis Food protein-inducedallergic syndrome Food protein-inducedenterocolitis of IgEandnon-IgE) (an EGIDthatisamixture Eosinophilic esophagitis Disorder associated with TABLE C. Tests to diagnose non-IgE-mediated food allergy food allergy

Food elimination Atopy patchtest Food elimination Atopy patchtest Food elimination Oral foodchallenge Food elimination Oral foodchallenge Atopy patchtest sIgE test Skin prick/puncturetest Test

Can the test diagnose DIAGNOSIS OF FOOD ALLERGY FOOD OF DIAGNOSIS

food allergy?

Yes Yes Yes Yes Yes Yes Yes Yes No No No

17 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 18 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES A childshouldberetestedtoconfirmthat APhasbeenoutgrown. What elseyou shouldknow: recurrence ofsymptomsfollowinganoralfoodchallengetodiagnose AP. history, theabsenceofsymptomswhileavoidingcausativefood, and Guideline 15recommendsthatyourhealthcareprofessionaluseamedical Food protein-induced allergic proctocolitis ALLERGY FOOD OF DIAGNOSIS urticaria causedbyfoodandinvolvingIgE. tests orSPTs, andpositiveimmediateresponsesto APTs todiagnosecontact the absenceofsymptomswhileavoidingcausative food, positivesIgE Guideline 18suggeststhatyourhealthcareprofessionaluseamedicalhistory, and onethatdoesnot. Contact urticariaisadiseasethatcomesintwoforms, onethatinvolvesIgE How should your healthcare professional diagnose contact urticaria? to diagnosesystemic(whole-body)contactdermatitis. the absenceofsymptomswhileavoidingcausativefood, andpositive APTs Guideline 17suggeststhatyourhealthcareprofessionaluseamedicalhistory, Systemic contact sIgE antibodies, buttheremustbeother clinicalsignstosupportthediagnosis. What elseyou shouldknow: Positive APT reactionsindicatethepresence of positive APTs todiagnose ACD. history, theabsenceofsymptomswhile avoidingthecausativefood, and Guideline 16recommendsthatyourhealthcareprofessionaluseamedical Allergic

AP usuallyendsbetweenages1and2years.

also usesnuts.” The inclusionofthesewarninglabels isvoluntary. as “may containtraceamountsofnuts” or “may be preparedinafacilitythat However, thelawdoesnot requireorsuggestwordingforwarninglabels, such shellfish) arepresentasingredientsinpreparedfoods. food allergens(milk, egg, peanut, treenuts, soy, wheat, fish, andcrustacean Protection Act of2004requiresfoodlabelstolistwhichtheeightmajor What elseyou shouldknow: “made inafacilitywhereallergen-containingproducts aremade.” warning labelssuchas “this productmaycontaintraceamountsofallergen” or on howtounderstandingredientlistsfoodlabels andavoidproductswith Guideline 24suggeststhatifyouhavefoodallergy, youshouldreceivetraining nutritional counselingandregulargrowthmonitoring. Guideline 23recommendsthatchildrendiagnosedwithfoodallergyreceive reduces theseverityofeczema, asthma, orEoEifyoudonothavefoodallergy. What elseyou shouldknow: may beallergenicasawaytomanageyoureczema, asthma, orEoE. have notbeendiagnosedwithfoodallergy, youshouldnotavoidfoodsthat Guideline 22recommendsthatifyouhaveeczema, asthma, orEoEandyou also shouldbeavoided. professional shouldworkwithyoutodecidewhethercertainrelatedfoods safest waytomanagefoodallergyandpreventsymptoms. Your healthcare What elseyou shouldknow: Noteatingtheallergenicfoodiscurrently allergenic food. in combinationwitheczema, asthma, orEoE, youshouldavoidthe IgE-mediated foodallergy, non-IgE-mediatedfoodallergy, orfoodallergy Guidelines 19 through 21 How should food allergy be managed? and PreventionofFoodAllergy Management ofNonacuteAllergicReactions

MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT

recommend that if you have been diagnosed with

The U.S. Food Allergen Labeling andConsumer There isnoevidencethatavoidingallergenicfoods

19 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 20 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES whether itissafetointroducecertainfoodsintothechild’s diet. Follow-up testingcanhelpyouandyourhealthcareprofessionaldecide What elseyou shouldknow: Somechildrenoutgrowtheirfoodallergies. follow-up testing. Guideline 25suggeststhatindividualswithfoodallergyshouldreceive ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT 1 they cansafelyreceiveegg-based . anaphylaxis shouldtalk with theirhealthcareprofessionaltodiscusswhether may beatriskifinjected withthesevaccines. Peoplewithouta historyof amounts ofeggprotein, peoplewithamedicalhistoryofanaphylaxistoegg amounts ofeggprotein. Although theseegg-basedvaccinescontainverylow Several vaccinesaremadeusingchickeneggs. These vaccinescontainvarying What are the recommendations for vaccines for patients with ? plan thatisageandculturallyappropriate. on howtoavoidfoodallergensanddevelop anemergencymanagement Guideline 30recommendsthatyoushouldreceiveeducationand information find moreinformationathttp://www.clinicaltrials.gov. If youwouldliketoparticipateinclinicaltrialsofimmunotherapy, youcan been littlestudyofimmunotherapywithcross-reactive allergens. therapeutic effectanddurationofbenefithavenotbeenproven. Therehas of allergen-specificimmunotherapyhavehadpromisingresults, butthe Why notusethem? allergens totreatfoodallergyinvolvingIgE. use allergen-specificimmunotherapy orimmunotherapy withcross-reactive Guidelines 28and29recommendthatyourhealthcareprofessionalnot can increaseyourriskofinfection. allergic reactionstofoods. However, theyhavesideeffectsandinsomecases What elseyou shouldknow: Drugsareavailablethatmaypreventordecrease IgE- ornon-IgE-mediatedfoodallergy. Guidelines 26and27statethattherearenomedicationsavailabletoprevent caused by foods? Are available to prevent and treat allergic reactions

This informationdiffers slightlyfromtheGuidelinesandreflects moreup-to-dateguidanceaboutegg-based vaccines.

The safetyofimmunotherapyisuncertain. Earlystudies

1

reactions. the amountofeggproteininvaccineandpatient’s historyofallergic egg allergy(summarizedintableD). The recommendationsarebasedon inserts (PIs)providerecommendationsforgivingvaccinestopatientswith Academy ofPediatrics(AAP)RedBook, andvaccinemanufacturer’s package The Advisory CommitteeonImmunizationPractices(ACIP), the American egg proteincontentofthese vaccinesisverylow. What elseyou should know: MMRandMMRV vaccinesaresafebecausethe (MMR) andforMMRwithvaricella(MMRV). history ofseverereactions, receivevaccinesformeasles, , andrubella Guideline 31recommendsthatchildrenwitheggallergy, eventhosewitha or moreportionstoreducethepotentialriskofan allergicreaction. protocol, amethodthatinvolvesadministeringsingledoseofvaccineintwo In somecases, yourhealthcareprofessionalmaychoosetouseadesensitization AAP, AmericanAcademyofPediatrics;ACIP, AdvisoryCommitteeonImmunizationPractices; AL .21 CPadAPRdBo eomnain n Iinformation PI and recommendations Book Red AAP and ACIP 2010 D. TABLE Yellow fever Rabies Influenza and varicella mumps, rubella, rubella/measles, Measles, mumps,

o diitrn acnst ainswt g allergy egg with patients to vaccines administering for

vaccine ifnecessary may beusedtogivethe desensitization protocols Contraindicated, but Use caution Consult aphysician May beused MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT ACIP

vaccine ifnecessary may beusedtogivethe desensitization protocols Contraindicated, but recommendation No specific Contraindicated May beused AAP Red Book

PI, packageinsert. provided inthePI desensitization protocols Skin testingand caution May beusedwith Contraindicated caution May beusedwith

PI 21 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 22 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES are thinkingaboutgettingtheinfluenzavaccine. You shouldtalkwithyourhealthcareprofessionalifyouhaveeggallergyand from virusesthatarealivebutweakenedsotheycannotcausedisease). viruses thataredeadsotheycannotcausedisease)orlive-attenuated(made This statementappliestoinfluenzavaccinesthatareinactivated(madefrom asthma, oranaphylaxis. vaccine. Severeallergicreactionsincludeahistoryofhives, with ahistoryofsevereallergicreactionstoeggproteinreceivetheinfluenza Currently, thereisnotenoughclinicalevidencetorecommendthatapatient ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT that avoidingnonfoodallergens hasanyeffectonthedevelopmentoffood allergy, orahistory ofanythese. There isnotenoughevidencetosuggest a biologicalparentorsibling withexistinghayfever, asthma, eczema, orfood What elseyou shouldknow: crustacean shellfish). eight majorfoodallergens(milk, egg, peanut, treenuts, soy, wheat, fish, and mites, pollen, orpetdander) ortofoodsthatmaybecross-reactivewiththe allergy, youshouldnotlimitexposuretononfoodallergens(forexample, dust Guidelines 32and33suggestthatifyouareatriskfordevelopingfood food allergy from developing? Can avoiding nonfood allergens and cross-reactive food allergens prevent decide whetheritissafetoreceivethevaccine. to thevaccine. Basedontheresults, youandyourhealthcareprofessionalcan Your healthcareprofessionalcanevaluateyoutoseewhetherareallergic concentration maynotbelowenoughtosafeforpatientswitheggallergy. amount ofeggproteininotherrabiesvaccinesortheyellowfevervaccine. The protein andissafeforpeoplewitheggallergy. Nodataareavailableonthe What elseyou shouldknow: recommend thisapproach, whichalso isapprovedbythevaccinemanufacturer. undergo allergyevaluationandtestingwiththevaccine. The ACIP and AAP you haveahistoryofsevereallergicreactionstoeggproteins, unlessyoufirst The Guidelinesrecommendagainstreceivingyellowfeverorrabiesvaccinesif Rabies and yellow fever vaccines

A personatriskfordevelopingfoodallergyhas The Imovaxrabiesvaccinedoesnotcontainegg

,

family historyoffoodallergy. Children athighriskarethosewhoalreadyhavesevereallergicdiseaseora egg, andpeanut)tochildrenwhoareatahighriskofreactingthesefoods. food allergytestingbeforeintroducinghighlyallergenicfoods(suchasmilk, The Guidelinesstatethatthereisnotenoughevidencetorecommendroutine highly allergenic foods into the diet? Should a child at high risk for food allergy be tested prior to introducing developing inherchild. orwhenbreastfeedingasawaytoprevent foodallergyfrom Guideline 36recommendsthatamothernotrestrictherdietduring Can food allergy be prevented? These childrenmaybenefitfromafoodallergyevaluation. at riskfordevelopingfoodallergy, especiallyallergytomilk, egg, andpeanut. What elseyou shouldknow: Childrenwithmoderatetosevereeczemaare eczema andahistoryofallergicreactionstospecific food. than 5yearsoldandhaseczemathatdoesnotgoawaywithtreatment, a childformilk, egg, peanut, wheat, andsoyallergy ifthechildisyounger Guideline 35suggeststhatahealthcareprofessionalshouldconsiderevaluating Should a child with eczema be tested for food allergy? food allergyinchildrenwhohavenosymptomsorriskfactors. Why not? before highlyallergenicfoodsareintroducedintothediet. and nofamilyhistoryoffoodallergyshouldnotbetestedfor Guideline 34suggeststhatachildwithnopreexistingsevereallergicdisease into the diet? history of food allergy be tested prior to introducing highly allergenic foods Should a child with no preexisting severe allergic disease and no family for inadequatenutrition. cause allergicsymptoms. Avoiding foodsunnecessarilycouldputyouatrisk allergy orthatfoodscross-reactwiththemajorallergenicwill

There isinsufficientevidencetosuggestanybenefittestingfor MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT

or has

23 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 24 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES Guideline 40 prevent foodallergy. results, haveexaminedwhethertheuse ofhydrolyzedinfantformulascan What elseyou shouldknow: Onlyalimitednumberofstudies, with varying exclusively breast-fed. allergy fromdevelopinginchildrenatriskforfoodandwhoarenot hydrolyzed infantformulasinsteadofcow’s milkformulatopreventfood Guideline 39suggeststhatparentsandcaregiversshouldconsiderusing benefit ingivinganinfantsoymilkformula. What elseyou shouldknow: developing. soy milkformulainsteadofcow’s milkformulatopreventfoodallergyfrom Guideline 38doesnotrecommendgivinganinfantatriskforfoodallergy increases thelikelihoodthataninfantwilldevelopfoodallergy. What elseyou shouldknow: age 4to6months, unlessbreastfeedingisnotadvisedformedicalreasons. Guideline 37recommendsthatamotherexclusivelybreastfeedherinfantuntil of foodallergyinherchild. mother’s dietwhilesheispregnantorbreastfeedingpreventsthedevelopment What elseyou shouldknow: ALLERGY FOOD OF PREVENTION AND REACTIONS ALLERGIC NONACUTE OF MANAGEMENT 2 food containingmilk, eggs, peanut, treenuts, soy, orwheat. prevent allergicdiseasesfromdeveloping. This includesgivinganinfanta the introductionofsolidfoodstoaninfantbeyond 4to6monthsofage What elseyou shouldknow: of age. including potentially allergenic foods, to an infant beyond 4 to 6 months

was notconsidered by theexpertpanel.Pleasecheckwithyour healthcareprofessionalforspecific guidance. because oftheriskchoking.Thisisan importantsafetyconsideration.ThisinformationisnotfoundintheGuidelinesand healthcare professionalsgenerallyadvise thatnoinfantoryoungchildshouldbegivenwholepiecesofpeanutstree nuts

suggests that you should

There isneitherlong-termharmnorsignificant There isnostrongevidencethatbreastfeeding There isnoevidencetosuggestthatrestrictinga There isnoevidencethatsupportsdelaying not

delay introducing solid foods,

2

food allergy. history ofallergicreactionstofoodorhavebeenpreviouslydiagnosedwith seek immediatetreatmentandtellyourhealthcareprofessionalifyouhavea What elseyou shouldknow: Ifyouareexperiencingsymptomsofanaphylaxis, • • • • with anaphylaxisshouldunderstandthefollowing: Guideline 41recommendsthatahealthcareprofessionaldiagnosingpatient anaphylaxis caused by food? What should your healthcare professional understand when diagnosing Caused byFood Diagnosis andManagementofAnaphylaxis • • an anaphylacticepisode: experience anyoneofthefollowingthreeconditions, you maybeexperiencing The symptomsofanaphylaxisvaryandcanbedifficulttorecognize. Ifyou The symptoms of anaphylaxis The limitedvalueoflaboratorytestsduringananaphylacticepisode and howtheseconditionsmayaffecttreatment Conditions suchasasthmathatmaybeassociatedwithfoodallergy Timing ofsymptomsinrelationtoexposure totheallergenicfood Signs andsymptomsofanaphylaxis minutes toseveralhoursafterexposureasuspected allergenicfood: You havetwoormoreofthefollowingsymptoms thatoccurwithin pressure (pale, weakpulse, confusion, lossofconsciousness). and GItract), orboth. You alsohavetroublebreathing oradropinblood mucosal tissue(moistliningofthebodycavities, suchasthenose, mouth, Your symptomsappearwithinminutesto several hoursandinvolveskin, – –

Trouble breathing lips, tongue, orthebackofthroat Hives, itchiness, orrednessalloveryourbodyand swellingofthe

DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED BY FOOD BY CAUSED ANAPhYLAxIS OF MANAGEMENT AND DIAGNOSIS

25 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 26 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED bY FOOD bY CAUSED ANAPhYLAxIS OF MANAGEMENT AND DIAGNOSIS begin withanintramuscular (IM)injectionofepinephrine. Guideline 42recommendstreatinganaphylaxis immediatelyaftersymptoms How should anaphylaxis be treated? challenge testcanthenbedonetoconfirmthediagnosis offoodallergy. laboratory testingmaysuggestwhatfoodscaused thereaction. An oralfood an anaphylacticreaction. After thepatienthasbeensuccessfullytreated, There arenousefullaboratoryteststoperformwhen apatientisexperiencing treatment. treat highbloodpressurealsomayaffectsymptom severityandresponseto increase theriskofdeathfromanaphylaxis. Medicationssuchasthosethat Diseases suchasasthma, chroniclung disease, andcardiovasculardiseasemay reactions topeanutortreenuts. associated withdeathsduetoanaphylaxis. Mostofthesecasesareallergic What elseyou shouldknow: • • • An anaphylacticreactioncanoccuras: Timing of anaphylaxis • the initialreaction. A single, long-lastingreactionthatcontinues forhoursordaysfollowing occur between8and72hoursafterthefirstreaction. seem toimproveandgoawaybutthenreappear. The secondreactioncan Two reactions. The firstreactionincludesaninitialsetofsymptoms that hours. Symptomsdonotrecurlaterin relationtothatepisode. food andgetsbetterwithorwithouttreatmentwithinthefirstminutesto A singlereactionthatoccursimmediatelyafterexposuretotheallergenic allergy. to severalhoursafterexposureafoodwhichyouknowhavean Your bloodpressuredrops, leading toweaknessorfainting, withinminutes – –

GI symptomssuchasabdominalcrampsorvomiting Drop inbloodpressure

The delayeduseofthedrugepinephrinehasbeen

you atsignificantlyincreasedriskforalife-threatening allergicreaction. secondary treatment. Givingantihistaminesinsteadofepinephrinemayplace What elseyou shouldknow: possible, withthelegsraisedandgivenoxygenIVfluid. When medicalhelparrives, thepatientshouldbeplacedlyingdown, if • • • experts advisethatyoudothefollowingasquicklycan: If youorsomeoneknowishavingananaphylacticepisode, health necessary togiverepeatdoses. and deathwithin30to60minutes. actsimmediately, butitmaybe anaphylaxis. Delaysingivingepinephrine topatientscanresultinrapiddecline What elseyou shouldknow: Epinephrineshouldbegivenimmediatelytotreat • • • • • • may givethepatientanyoffollowingsecondarytreatments: position tohelprestorenormalbloodflow. Ahealthcareprofessionalalso After epinephrinehasbeengiven, thepatientmaybeplacedinareclining transferring thepatientto anemergencyfacility. The healthcareprofessional experiencing anaphylaxis byimmediatelygivingIMepinephrineandthen Guideline 43recommendsthatahealthcare professionalshouldassistpatients How should anaphylaxis caused by food be managed? in thehospital. Call 9-1-1ifyouarenotinahospital, orsummonaresuscitationteam If anauto-injectorisavailable, inject epinephrine intothethighmuscle. Remove theallergenicfoodfrommouthorskin. Intravenous (IV)fluids Supplemental oxygentherapy heart rate Medications tohelprestorenormalbloodpressureandmaintaina topreventpain, swelling, andredness torelieveitchingandhives Medications tohelpthepatientbreathe

Antihistamines shouldonlybeusedasa DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED bY FOOD bY CAUSED ANAPhYLAxIS OF MANAGEMENT AND DIAGNOSIS

27 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 28 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES • • • What elseyou shouldknow: • • • • • provide thefollowing: Before leavingemergencymedicalcare, yourhealthcareprofessionalshould necessary treatment. should observethepatientfor4to6hoursorlongerandoverseeanyfurther FOOD BY CAUSED ANAPhYLAxIS OF MANAGEMENT AND DIAGNOSIS you areunabletoinjectyourself Instruct familyandfriendsonhowtousetheauto-injectorfortimeswhen when itexpires(usuallyafter1year) liquid withintheinjectorremainsclear(discardifnotclear), andknow Know howtoproperlystoreyourauto-injector, make surethecolorof Always carryyourepinephrineauto-injectorandknowhowtouseit An anaphylaxisemergencyactionplan(seesampleonthenextpage) anaphylaxis, andgivingIMepinephrine Education aboutallergenavoidance, recognizing thesymptomsof anaphylaxis walletcardthatalertsothersofthefoodallergy Information onwheretogetmedicalidentificationjewelryoran as anallergist/immunologist A follow-upappointmentoranwithaclinicalspecialistsuch on howtousetheauto-injector An epinephrineauto-injectororaprescriptionfortwodosesandtraining ______Only afewsymptomsmaybepresent.Severityofcanchangequickly. • • • • • • SYMPTOMS OF ANAPHYLAXIS INCLUDE: Wear medicalidentificationjewelrythatidentifiestheanaphylaxispotentialandfoodallergen triggers. Current medications, if any: Other health problems besides anaphylaxis: Asthma: ALLERGY TO: NAME: (Adapted FromJACIPublications Sample AnaphylaxisEmergencyActionPlan †Adapted fromJAllergy ClinImmunol1998;102:173–176and JAllergyClinImmunol2006;117:367–377. Doctor’s Signature/Date COMMENTS: DO NOT HESITATE TO GIVE EPINEPHRINE! 3. 2. IMPORTANT: Asthma inhalers and/or antihistamines can’t be depended on in anaphylaxis! ______Other /dose/route: Note: Patientsshouldbeallowedtoself-carryandself-administerepinephrine. 1. WHAT TO DO: * Somesymptomscanbelife-threatening!ACT FAST! ❏ hEART* LUNG*—shortness ofbreath,cough, GUT—vomiting, diarrhea,cramps SKIN—itching, hives,redness,swelling ThROAT MOUTh—itching, swellingoflipsand/ortongue 3 home #3: home #2: home #1: EMERGENCY CONTACTS CALL 9-1-1orRESCUESQUAD(beforecallingcontacts)! ❏ INJECT EPINEPHRINEINTHIGHUSING(checkone): EpiPen (0.3mg) EpiPen Jr(0.15mg) ______—weak ,dizziness,passingout *—itching, tightness/closure,hoarseness ______❏

Yes (high risk for severe reaction) ______❏ ❏ Adrenaclick 0.30mg Adrenaclick 0.15mg work work work † )

______cell ______

Parent’s Signature (for individuals under age 18 years)/Date ______

SAMPLE ANAPhYLAxIS EMERGENCY ACTION PLAN ACTION EMERGENCY ANAPhYLAxIS SAMPLE cell cell

______AGE: ❏

No

______29 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 30 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES molecule involvedinallergy. interacting withallergenproteinsorfromthedirect releaseofhistamine, a allergen. The hivescanbe localorwidespread. They arecausedbyantibodies Contact urticaria(hives)occurswhentheskincomesincontactwith an anaphylaxis. immediate medicalattention. angioedemaisacommonfeatureof upper airwayisinvolved, swellinginthevoiceboxisanemergencyrequiring occurs withhivesand, ifcausedbyfood, istypicallyIgE-mediated. When the organs, orintheupperairway(nose, backofthethroat, voicebox). Itoften Angioedema isswellingduetofluidcollectingundertheskin, intheabdominal begins veryrapidly, andmaycausedeath. system (forexample, skinandrespiratory tractand/orgastrointestinaltract), Anaphylaxis isaseriousallergicreactionthatinvolvesmorethanonebody allergic reactionintheinfant. because themother’s milkcontainsfoodproteinsfromherdietthatcausean symptoms tooccur. Manyinfantshave AP whilebeingbreast-fed, probably professional mustrelyonamedicalhistoryshowingthatcertainfoodscause Because therearenolaboratoryteststodiagnosefood-induced AP, ahealthcare but havevisiblespecksorstreaksofbloodmixedwithmucusintheirstool. Allergic proctocolitis(AP)isadisorderthatoccursininfantswhoseemhealthy skin thatmayornotcontainfluid. Symptoms includeitching, redness, swelling, andsmallraisedareasonthe . The allergicreactioninvolvesimmunecellsbutnotIgEantibodies. reaction tofoodadditivesormoleculesthatoccurnaturallyinfoodssuchas Allergic contactdermatitis(ACD) isaformofeczemacausedby anallergic while remainingresponsivetounrelatedproteins). immune systemtoignorethepresenceofoneormorefoodproteinallergens allergen—with thegoalofinducingimmunetolerance(theability is givenincreasingdosesofanallergen—forexample, milk, egg, orpeanut Allergen-specific isatypeoftreatmentinwhichpatient Glossary GLOSSARY

in adults, most oftenrelatedtoeatingcrustaceanshellfish. , oat, orothercerealgrains. A similarconditionalsohasbeenreported protein arethemostcommon causes, butsomestudiesreport reactions to food isremovedfromthe infant’s diet, symptomsdisappear. Milkandsoy vomiting, diarrhea, andfailuretogainweightorheight. When theallergenic disorder thatusuallyoccursinyounginfants. Symptomsincludechronic Food protein-inducedenterocolitissyndrome(FPIES)isanon-IgE-mediated likely torecurinpatients. patients whohaveexperiencedexercise-inducedanaphylaxis. This reactionis that occursduringphysicalactivity. Foodisthetriggerinaboutone-thirdof Exercise-induced anaphylaxis isatypeofsevere, whole-bodyallergicreaction anaphylaxis. blood vessels, andopenstheairways. Epinephrineisthebesttreatmentfor Epinephrine ()isahormonethatincreasesheartrate, tightensthe mechanisms appeartobeinvolvedinEoE. eosinophils collectintheesophagus. Both IgE-andnon-IgE-mediated but howitisrelatedunclear. Itoccurswhentypes ofimmunecellscalled Eosinophilic esophagitis(EoE)isadisorderassociatedwithfoodallergy, Enteropathy isadiseaseoftheintestine. Enterocolitis isaninflammationofthecolonandsmallintestine. a historyofallergyandeczemaisatriskfordevelopingfoodallergy. microbes, andallergens. A personwhohasabiologicalparentorsiblingwith to maintainaneffectivebarrieragainstenvironmentalfactors, suchasirritants, causes ofthediseaseareunclear. There maybeaproblemintheskin’s ability include scaly, itchyrashesandblistering, weeping, orpeelingoftheskin. The Eczema (atopicdermatitis, atopiceczema)is a diseaseoftheskin. Symptoms foods. Inthiscase, lobsterwouldbeacross-reactivefood. also maybeallergictolobster, becauseshrimpandlobsterarecloselyrelated with thecross-reactivefood. Forexample, apersonwhoisallergictoshrimp the immunesystem. An antibodythatreactswiththeallergenicfoodalso reacts Cross-reactive foodsarethatseenassimilartoallergenicby andasthma. cortisone. These drugsareusedtotreatinflammatorydiseases, suchas Corticosteroids areaclassofdrugssimilartothenaturalhormone

GLOSSARY

31 NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 32 NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES allergen or is exposed to it though a skin cut or puncture, symptoms develop. through contactwiththeskin. Ifthe person subsequentlyswallowsthe dermatitis, apersonfirstdevelopsspecific IgEantibodiestotheallergen eczema, fever, , andstuffynose. To developsystemiccontact Systemic contactdermatitisisararedisorderwithsymptomsthatinclude food, notaftersimplytouchingthefood. ingested. SpecificIgEantibodiestothefoodareonlymadeaftereating Noncontact food allergy developsasaresultofthefoodallergenbeing to asimilarallergenthatiscausingreaction. which apatientisgivenincreasingdosesofanallergentoinducetolerance Immunotherapy withcross-reactive allergens isatypeoftreatmentin GLOSSARY

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