Food Allergy

dr.
dr. James LL.. Alvin Sinaga Sp.A
 Definition
• A phenomenon in which adverse
reactions are caused through
antigen--specific immunological
antigen
mechanisms after exposure to a
given food.

JSPACI 2016
JPGFA 2012
 Epidemiology
Prevalence of Food
allergies in USA Food Children Adults
Milk 2,5% 0,3%
Egg 1,3% 0,2%
Peanut 0,8% 0,6%
Tree Nuts 0,2% 0,5%
Fish 0,1% 0,4%
Shell fish 0,1% 2,0%
Overall 6,0% 3,7%
Allergy for the Clinician page 312
 Foods triggering anaphylaxis in Singapore children
in 1992 – 1996 and 2010 presenting to NUH
Percentage Mean age
n=124 n=73 n=124 n=73
1992-1996
1992- 2010 1992-
1992-1996 2010
1 Egg and milk 11% 19,2% 0,7 1,8
2 Bird's nest 27% 2,7% 4,5 11,6
3 Chinese herbs 7% 2,7% 5,0 3,0
4 Crustacean sea food 24% 17,6% 11,0 8,5
5 Peanuts 0% 11% 0 4,8
6 Others* 30% 46,6% 7,0 6,0
*Chicken, duck, ham, fruits (banana, rambutan), cereals, gelatin and spices
Van Bever H et al 2011
 The rise in allergy cases
• 30
30--40 year
– Germ free
Hygiene Hypothesis
– Food additives
• Sulphites (sulphur dioxide)
preservatives
(soft drink), sausage, burger & dried fruits &
vegetables
asthma allergic phenols
• Benzoate
preservatives in soft drink

Asthma & Eczema
Perinatal factor and the development
of Food allergy in children
Risk of FA
• CS
• Preterm birth
• LGA
• Low 5 minutes AS

• ↓ risk
• Born very preterm
JACI September 10, 2018
 Adverse Food Reaction
Guidelines for the diagnosis & management of Food Allergy in the US

Adapted from Boyce et al. JACI, 2010

Causes

Image Courtesy of gulfnews.com

Proportion of causative foods
……causes

Breakdown of causative foods of immediate-

immediate-type FA
https://www.sciencedirect.com/science/article/pii/S1323893017300059
 ……causes
Foods Responsible for the Majority of Food-
Food-Allergic Reactions
Older Children /
Infants Children
Adults
Cow's milk Cow's milk -
Eggs Eggs -
Peanuts Peanuts Peanuts
Soy Soy -
- Wheat -
- Tree nuts (walnut, cashew, cashew, etc) Tree nuts
- Fish Fish
- Shellfish Shellfish
Pediatric Allergy box 51-
51-1 page 536
 ……causes
Age at Onset of Food Allergy Against Different Foods

Age (yr) Food

0-1 Milk, egg
1-2 Peanuts, fish in Scandinavian
countries
>2 Fruits, legumes, vegetables
Pollen--related cross-
Pollen cross-reactivities
>3 (oral allergy syndrome)
Pediatric Allergy table 46-
46-1 page 488
Food allergen component-
component-specific IgE tests
covered by nationwide health insurance.
Crude antigen Allergenic component
Egg white Gal d 1 (Ovomucoid)
Bos d 4 (α
(α-Lactoalbumin)
Cow's milk Bos d 5 (β
(β-Lactoglobulin)
Bos d 8 (Casein)
Wheat Tri a 19 (ω-
(ω-5 gliadin)
Soybean Gly m 4 (PR-
(PR-10)
Peanut Ara h 2 (2S albumin)
Latex Hev b 6.02
https://www.researchgate.net/figure/Food-allergen
https://www.researchgate.net/figure/Food- allergen--component
component--specific
specific--
IgE
IgE--tests
tests--covered
covered--by-
by-nationwide-
nationwide-health
health--insurance_tbl4_314652488
Crude antigen and Allergenic component of fishes
Clinical Features
Clinical Features of Food Allergy in Children
Clinical Features of Food Allergy in Children
Pediatric Allergy table 46-
46-2 page 488
 Pathogenesis
Sequence of a Typical "full blown" IgE
IgE--mediated Food Allergic Reaction
Itch (neck, trunk)
trunk)

Urticaria (spreading over the whole body)

Swelling of lips - eyes

Swelling of tongue - itchy throat

Difficult breathing - wheezing + rhinitis (sneezing) + Conjunctivitis

Fainting - coma - anaphylactic shock

Van Bever H. Food Allergy. In: Allergic Diseases in Children. 2009 page 163
 Outgrow
• Children are often outgrow allergies to milk,
eggs, soy and wheat
• Peanut, tree nut, fish and shellfish allergy
tend to persist throughout adulthood

Why?
• 20% of peanut allergy can outgrow
 Natural History of Food Allergy
Food Allergy Often Outgrown by Adolescence
Milk
Eggs
Soy
Wheat
Food Allergy Often not Outgrown by Adolescence
Peanuts
Tree nuts
Fish
Shellfish Pediatric Allergy box 51-
51-4 page 537
 Differential Diagnoses
Infant
• Upper gastrointestinal symptoms
– Infection
– Colic*
– Gastroesophageal reflux*
– Pyloric stenosis (defined age group)
– Hiatal hernia
– Tracheoesophageal fistula
*Could be caused by food allergy
Pediatric Allergy box 46-
46-2 page 490
 ……differential diagnoses
Infant
• Lower gastrointestinal symptoms
– Enzyme deficiency
– Disaccharides deficiencies (lactase, sucrase-
sucrase-
isomaltase))
isomaltase
– Glucose
Glucose--galactose malabsorption
– Galactosemia
– Phenylketonuria
– Infection
– Constipation* *Could be caused by food allergy
– Hirschaprung’s disease
Pediatric Allergy box 46-
46-2 page 490
 ……differential diagnoses
Toddler
• Infection
• Toddler’s diarrhea
• Gastroesophageal reflux*
• Constipation*
• Lactose intolerance
• Malabsorption (celiac disease, cystic
fibrosis)
*Could be caused by food allergy
• Bizarre diets
Pediatric Allergy box 46-
46-2 page 490
 ……differential diagnoses
School--age child
School
• Infection
• Recurrent abdominal pain
• Lactose intolerance
• Malabsorption (celiac disease, cystic fibrosis,
Schwachman syndrome)
• Inflammatory bowel disease
• Eosinophilic gastroenteritis*
• Other causes (immunodeficiency, Henoch-
Henoch-
Schönlein disease) *Could be caused by food allergy

Pediatric Allergy box 46-

46-2 page 490
 Diagnosis
Algorithm for the
Management of
Food Allergy

https://openi.nlm.nih.gov/detailedresult.php?img=PMC3245440_1710-1492-7-S1-S7-2&req=4
 ……diagnosis
• Allergy focused clinical history
– The age of the child or young person when symptoms
fist started
– Speed of onset of symptoms following food contact
– Duration of symptoms
– Severity of occurrence
– Frequency of occurrence
– Setting of reaction (for example, at school or home)
– Reproducibility of symptoms on repeated exposure
– What food how much exposure to it causes a reaction
NICE 2011 page 8
 ……diagnosis
• Family history of allergy
Atopic Dermatitis (AD )
Asthma
Allergic Rhinitis (AR)

• Physical exam
• Growth & faltering
• Allergy related comorbidities (atopic eczema,
asthma, allergic rhinitis
 ……diagnosis
Skin Prick / Puncture Test
• To identify the food(s) that may causing the
IgE mediated food allergy
• Safe
• Result usually appear within 15-
15-30 minutes
• A positive SPT
wheal share
• A positive SPT result that you are allergic to
food
desensitisation
• Even when food allergy involved IgE
(–) SPT result to occur
 ……diagnosis
Skin Prick Test
 ……diagnosis
Total serum IgE (sIgE level)
• Don’t make a diagnosis based on the total
amount of sIgE anti body in serum. Why?
• There is not enough clinical evidence to show
that measuring total serum IgE level is sensitive
or specific enough to diagnose food allergy.
• The result of sIgE testing and SPT do not always
match up.
• Undetectable sIgE level occasionally occur in
people with food allergy.
 ……diagnosis
ImmunoCAP Level
Food Item ImmunoCAP Level
< 2 years of age
Egg > 2 KUa
KUa/L
/L
Milk > 5 KUa/L
KUa/L
> 5 years of age
Egg 7 KUa/L
KUa/L
Milk 15 KUa/L
KUa/L
Peanut 14 KUa/L
KUa/L
Tree Nuts 15 KUa/L
KUa/L
Fish 20 KUa/L
KUa/L
Allergy for the Clinician page 319
 ……diagnosis
Comparison between SPT and Specific IgE Determination
SPT IgE
Sensitive (young children) less sensitive than SPT
less specific than IgE specific
cheap expensive
immediate results wait for results (according to lab)
need normal skin for all patients
antihistamines suppress SPT no effect of any medication
not very painful painful
patient (and parents) can see the results patient has to be informed by doctor
Van Bever H. Food Allergy. In: Allergic Diseases in Children. 2009 page 178
Table test to identify allergens and diagnose
food allergy involving IgE

NIAID 2011 page 12

Elimination diet & oral food challenge
• To identify food responsible for some non IgE
mediated food allergy
• Done if no known laboratory test that are
diagnostic of causative food
• Convincing history plus clearing of the symptom
is sufficient to make the diagnosis of FA
• Elimination diet done for 2-
2-6 week.
• Prolonged elimination diet that omit multiples
of food might cause malnutrition
• Gold standard to diagnose non IgE mediated
food allergy
 Characteristics of Food Allergy
• Persistent symptoms
• Symptoms related to food intake
• Allergic predisposition
• Two or more different symptoms
• Symptoms in two or more different organs

Pediatric Allergy box 46-

46-3 page 491
Approximate rate of clinical reactivity to at least 1 other related food

Allergy for the Clinician page 315

Approximate rate of clinical reactivity to at least 1 other related food

Allergy for the Clinician page 315

Approximate rate of clinical reactivity to at least 1 other related food

Allergy for the Clinician page 315

Clinical Cross reactivity among food groups
1. Beef/veal : lamb = 50%
2. Fish: other fish > 50%
3. Cow milk : goat milk = 90%
4. Egg : chicken meat = < 5%
5. Cow milk : beef/veal = 10%
6. Tree nuts : others nuts = > 50%
7. Peanuts : tree nuts = 35%
8. Wheat : other grains = 25%
9. Peanuts : other legumes = < 10%
10. Soybean : legumes = < 5%
Allergy for the Clinician page 318
 Prevention
• Avoidance: no eating, no drinking, no
smelling ,no touching
• EBF 4-
4-6 minute
• Hypoallergenic diet in high risk baby
• Prebiotic & Probiotic usage
no evidence
• Early introduction of allergenic food. (LEAP
study)
Allergy 2014; 69: 1008 – 1025
Curr Allergy Asthma Resp. 2013;13:622
2013;13:622--630
JACI 2014; 133: 165-
165-171
 Management of Treatment
Treatment of Food Allergy
• Avoidance
( learn to avoid and to read labels!)
• Emergency treatment
• Immunotherapy
• (Prevention …) (other talk)
 Referral to Allergist?
• The Child or Young person has:
– Faltering growth in combination with one or
more of the gastrointestinal symptoms
– Not responded to single-
single-allergen elimination diet
– Had one or more acute systemic reactions
– Had one or more severe delayed reactions
– Confirmed IgE
IgE--mediated food allergy and
concurrent asthma
– Significant atopic eczema where multiple or
cross--reactive food allergies are suspected by the
cross
parent or career
 ……referral to allergist?

• There is:
– Persisting parent al suspicion of food allergy
(especially in children or young people with
difficult or perplexing symptoms) despite a lack
of supporting history
– Strong clinical suspicion of IgE
IgE--mediated food
allergy but allergy test results are negative
– Clinical suspicion of multiple food allergies

©Nice 2018
https://www.nice.org.uk/terms--and-
https://www.nice.org.uk/terms and-conditions#notice-
conditions#notice-of-
of-right
 Food Allergy and Immunization
Vaccine ACIP AAP Red Book PI

MMR/
MMR/ May be used May be used May be used with cautions
MMRV

Influenza Consult a physician Contraindicated Contraindicated

Rabies Use caution No specific May be used with caution

recommendation
Yellow Contraindicated, Contraindicated, but Skin testing and
fever but desensitization desensitization desensitization protocols
protocols may be protocols may be provided in the PI
followed to used to give the
administer vaccine vaccine if necessary
if necessary

NIAID 2011 page 21

 Conclusion
• Prevalence of food allergy higher in children
compare to adult
• Diagnosis based on history, physical exam,
immunology test, elimination and oral food
challenge test
• Peanut allergy is the highest mortality
• Outgrow is common before adult
• Prevention is possible
• Treatment focused on non acute and acute
severe reaction
 Case
1. A 4 week old infant has had chronic vomiting,
bloody / mucous diarrhea and poor growth.
She is admitted to the hospital with
dehydration a acidemia and elevated WBC
count. She receives IV hydration over the next
2 days and her condition improves. The child is
suffering from.
A. Cow’s milk allergy
B. Amoebic dysentery
C. Celiac disease
D. Non IgE mediated food hypersensitivity
1.
……case
2. Any question you may ask to the parent ?
A. Yes
B. No
3. What kind of test you want to request?
A. Fecalysis
B. CBC
C. SPT
D. SIgE serum (Immunocap
(Immunocap))
1.

……case
2.
3.

4. If the fecalysis result is (-

(-) WBC count is 20.000 –
SPT test show wheal & flare 2x2mm and sIgE
serum 2 KUa
KUa/L.
/L. The child most probably suffering
from
A. Cow’s milk allergy
B. Food intolerance
C. Food protein induced enterocolitis syndrome
D. None
5. The most ideal test for Non IgE mediated food
hypersensitivity is:
A. Atopy patch test
B. Intra dermal skin testing
C. Food elimination and
D. Oral food challenge test
1.
2.

3.
4.
5.
……case

6. What is the ideal diet for this baby

A. Soy milk
B. Goat milk
C. Partial hydrolyzed formula
D. extensive hydrolyzed formula
The End