Allergic Disease - Latex-Fruit Syndrome Practice Guidance Toolkit 

Last Updated: 2017-03-20

Key Nutrition Issues

Allergy to natural rubber latex (NRL) is an IgE-mediated hypersensitivity reaction that is frequently seen in
health care workers and workers in the rubber industry (1). Individuals affected can develop symptoms
from direct contact with latex products; such as gloves, tubing or other rubber products; or by inhalation of
airborne NRL allergens in powder form, for example from latex gloves.

Latex-fruit syndrome is an allergic condition linked to NRL allergy (1). Affected individuals experience
allergic reactions on the ingestion of one or more plant foods that cross-react to NRL. Latex allergy is
normally a precursor; however, some individuals with latex-fruit syndrome are merely latex sensitized and
do not show clinical evidence of latex allergy. These reactions are due to the structural similarity
(homology) between certain NRL proteins and those found in plant foods. Since the foods involved are
primarily fruits, these cross-reactions between NRL and foods are termed latex-fruit syndrome, although
a large number of other plant foods have also been reported to provoke reactions.

Key Nutrition Issues

This toolkit discusses the following key nutrition issues:
Š foods that are liable to provoke allergic symptoms in individuals with latex allergy
Š the risk of allergic reaction in individuals with latex allergy served food from servers wearing latex
gloves.

See Additional Content:

Food Allergies - Latex-Fruit Background
Food Allergies - Food Allergies in Adults Background
Food Allergies – Oral Allergy Syndrome: Pollen-food Syndrome Practice Guidance Toolkit
Nutrition Care Process and Terminology Background.

Nutrition Assessment, Monitoring and Evaluation

Nutrition Assessment
The nutrition assessment of an individual with latex-fruit syndrome may include the following parameters in
the table below using NCP terminology.

Nutrition Monitoring and Evaluation

Some of the indicators from the table below that were measured in the nutrition assessment can be
repeated in the nutrition monitoring and evaluation steps.

Anthropometric Measurements

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 Š Height/Length
Š Weight
Š Weight Change
Š BMI
Š Body Compartment Estimates (waist circumference)
Š Growth Pattern Indices/Percentile Ranks

Anthropometric Comparative Standards – Adult

Measure NCP Terminology

Adult BMI Š Weight and Growth Recommendation

» Recommended body weight/BMI
Š Ideal/Reference Body Weight (IBW)
Š Recommended BMI

Waist As above
Circumference

Anthropometric Comparative Standards – Children

Measure Recommendation NCP Terminology

Birth to 24 The WHO Child Growth Š Weight and Growth

months Standards/Reference: Recommendation
Length-for-age For Birth to 5 years » Recommended body
Weight-for-age For 5 to 19 years weight/BMI/growth
Weight-for-length ΠDesired growth
Head pattern
Circumference
2 to 19 years of Growth Charts (WHO and
age CDC)
Height-for-age
Weight-for-age
BMI-for-age

Child BMI WHO Growth Charts Adapted

for Canada

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 UK-WHO 0-4 years
UK Growth 2-18 years

Food/Nutrition-related History

Š Food and Nutrient Intake

» Food and beverage intake
» Food intake
ΠAmount of food
ΠTypes of food/meals (e.g. avocado, chestnut, aubergine, Chinese date, apple,
apricot, bell pepper, carrot, coconut, cherry, cassava (manioc), celery,
cucumber, custard apple, fig, grape, guava, Indian jujube, jackfruit, loquat,
melon, mango, nectarine, pear, peach, passion fruit, pineapple, potato, plum,
papaya, strawberry, tomato and watermelon.
Š Medication and Complementary/Alternative Medicine Use
» Medications
ΠPrescription medication use (e.g. adrenaline auto-injector)
Š Knowledge/Beliefs/Attitudes
» Behaviour
ΠAdherence (e.g. avoidance of foods that have caused allergic reactions in the
past)

Food/Nutrition-related Comparative Standards

Š Energy Needs
» Estimated energy needs
Š Macronutrient Needs
» Estimated fat needs
» Estimated protein needs
» Estimated carbohydrate needs
» Estimated fibre needs
Š Estimated Fluid Needs
Š Micronutrient Needs
» Estimated vitamin needs
» Estimated mineral needs
Š See International Dietary Reference Values Collection.

Nutrition-focused Physical Findings

Š Skin (e.g. hives, pruritus, dermatitis)

Š Digestive System (e.g. local mouth irritation, nausea, vomiting and diarrhea)

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 Š Eyes (e.g. rhinoconjunctivitis)
Š Vital Signs (e.g. hypotension, airway obstruction, wheezing, anaphylaxis)
Š Other (e.g. angioedema, bronchial constriction)

Biochemical Data, Medical Tests and Procedures

Š IgE (natural rubber latex, latex extract, food-specific)

Š Skin Prick Tests
Š Oral Food Challenge

Client History

Š Personal History
» Personal data
ΠAge
» Patient/Client/Family Medical/Health History
ΠPatient/client or family nutrition-oriented medical/health history (atopy, changes
in frequency of allergic reactions; history of latex allergy; pollen allergy)

Nutrition Diagnosis

Sample PES Statements (problem, etiology, signs and symptoms using some NCP terminology)
This statement is provided as an example only, and will not apply to all individuals:
Š Food and nutrition-related knowledge deficit regarding which foods to avoid for latex-food allergy, as
evidenced by having three allergic reactions caused by eating avocado in the last month.

Nutrition Intervention

Nutrition Prescription Examples

Recommend:
Š Modified Diet
» Modifications for specific foods or ingredients (e.g. avoid foods that have provoked allergic
reactions in the past).

Food and/or Nutrient Delivery Example(s)

Š General/Healthful Diet
Š Modify Composition of Meals/Snacks (e.g. avoid foods that have provoked allergic reactions in the
past).

Nutrition Education Example(s)

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 Š Nutrition Education - Content
» Purpose of the nutrition education
» Nutrition relationship to health/disease
» Recommended modifications (e.g. avoid foods that have provoked allergic reactions in the
past).

Goals

Goals for an individual with latex-fruit allergy should be determined in conjunction with the client and
should be specific to the individual. Goals that are set should be time-sensitive, easily measured and
achievable by the nutrition intervention. Both short-term and long-term goals may be set. Examples of
short- and long-term goals include:
Š to avoid foods that have caused allergic reactions in the past, as soon as possible, and by the
next scheduled appointment (in one month)
Š to eat a healthy balanced diet by avoiding only the foods that have caused allergic reactions in the
past.

Allergic Disease - Latex-Fruit Syndrome Summary of Recommendations and Evidence

This Summary of Recommendations and Evidence synthesizes the Key Practice Point(s) for each
Practice Question (PQ) in this Knowledge Pathway. It is organized by the Nutrition Care Process and
contains statements or recommendations that have been graded using either the PEN or GRADE
approaches to critical appraisal. For additional information on the evidence and references, see the PQs in
this Knowledge Pathway.

Content
INTERVENTION
1. Latex (Natural Rubber (NRL) and Fruit- (LFS)) Allergy
Š Natural Rubber Latex and Latex-Fruit Syndrome Allergies
Š Foods Associated with LFS/NRL
Š Diagnosis of Latex Allergy

2. Food Handlers and Allergy Reaction Risk

1. Latex (Natural Rubber (NRL) and Fruit- (LFS)) Allergy

Natural Rubber Latex and Latex-Fruit Syndrome Allergies
Evidence Summary
Relationship Between Natural Rubber Latex and Latex-Fruit Syndrome Allergies
It is estimated that up to 70% of those allergic to natural rubber latex (NRL) have reactions to plant foods,
called latex-fruit syndrome (LFS). The type and severity of symptoms can vary but it has been reported
that anaphylaxis affects up to 50% of individuals. Most individuals develop symptoms to latex before the
manifestation of food allergy; however, some individuals with LFS will demonstrate food allergy without
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clinical symptoms of latex allergy.
{grade_b}

When taking an allergy-focused diet and nutrition history, if latex allergy is suspected it is important to
ask whether allergic reactions to foods have occurred or are suspected. Similarly, since reactions to
specific plant foods may precede a latex allergy, inquiries should be made about previous exposure to
latex and relevant allergy tests/interpretations should be obtained.
{grade_c}

Remarks
Allergy to natural rubber latex (NRL) is an IgE antibody-mediated hypersensitivity reaction that is
frequently seen in health care workers and workers in the rubber industry. Allergic symptoms when eating
plant foods is frequently reported by up to 70% of individuals with a latex allergy, referred to as latex-fruit
syndrome (LFS). Up to 50% of individuals with LFS experience anaphylaxis reactions.

Most individuals develop symptoms to latex before the manifestation of food allergy; however, some
individuals with LFS are sensitized to latex (have a positive test to latex but no clinical signs) and will
demonstrate food allergy without clinical symptoms of latex allergy.

Foods Associated with LFS/NRL

Recommendation
The foods most frequently causing severe reactions in latex-fruit syndrome are kiwi, banana and avocado.
These foods are commonly consumed in their raw state, but may still provoke reactions when cooked
depending on the allergens involved. Cooked chestnuts are also a characteristic food trigger of latex-fruit
syndrome, but if an individual reacts to chestnuts it should not be assumed that they are latex allergic.
Other allergens in chestnuts can provoke reactions not linked to NRL allergy. Other foods have been
linked to NRL in single case reports.

Food avoidance should be individualized, as not all individuals with latex-fruit syndrome will react to all
cross-reacting foods.

Evidence Summary
Toggle content

Remarks
Latex allergens include both class 1 and class 2 allergens including profilin and lipid transfer protein (LTP)
allergens. The allergens that are most usually involved in cross-reactions in latex-sensitized individuals are
called profilins, which are present in all latex-cross-reacting foods. Other plant food allergens such as LTP
allergens can also provoke reactions to plant foods, either with or without the involvement of pollen
antibodies.

See Additional Content: Food Allergies - Oral Allergy Syndrome: Pollen-food Syndrome Knowledge
Pathway.

Diagnosis of Latex Allergy

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Recommendation
In individuals with natural rubber latex (NRL) allergy, skin prick test (SPT) and specific immunoglobulin
E (IgE) tests to foods may not always predict clinical reactivity to a food reported to cause symptoms.
This is due to the nature of the allergens involved which may not always be present in commercially
available SPT and specific IgE test extracts due to their labile nature.

It is therefore important that advice given about foods to be avoided should be based primarily on the
clinical history of reported symptoms. In addition, since there are a significant number of similar common
allergic proteins in all plant foods, including latex, it is important to determine whether reported reactions
to a food are due to cross-reactivity with NRL or indicate a primary allergy to that food. Individuals who are
sensitized to latex may have positive SPT or specific IgE tests to a large number of foods but only need to
avoid those which are reported to have provoked symptoms. The same is true for other cross-reactive food
allergies such as pollen-food syndrome.

Evidence Summary
Toggle content

Remarks
See Additional Content: Food Allergies - Oral Allergy Syndrome: Pollen-food Syndrome Knowledge
Pathway.

2. Food Handlers and Allergy Reaction Risk

Recommendation
Very low quality evidence from case studies suggests that in strongly allergic individuals, unexplained
reactions to foods may be due to contamination from latex gloves. Latex exposure via food contaminated
by dietary staff wearing natural rubber latex (NRL) gloves may not be harmful to individuals sensitized but
asymptomatic to NRL; however, this will depend on which latex allergens the individuals are sensitized.

It has been shown that it is possible to reduce latex glove usage by food handlers through the use of
education programs. This action would potentially be beneficial not only to the latex-allergic individual
buying food, but also protect the food handler from developing latex allergy. The risk of using other types of
gloves is that the food handler could still develop a delayed allergic reaction to polyvinyl chloride (PVC)
gloves, although the risk to the consumer would be negligible. As well, alternative latex-free gloves may
not provide reliable barrier protection.

Evidence Summary
Toggle content

Remarks
The main allergens on the outside of a latex glove are Hev b 1 and Hev b 3, which do not contain any Hev
b 8. Individuals who are monosensitized to Hev b 8 are unlikely to react to NRL gloves, whereas individuals
with a primary latex allergy who are sensitized to Hev b 1 and Hev b 3 are more likely to react to NRL
gloves used by food handlers.

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Nutrition Monitoring and Evaluation

Type here

Nutrition Education and Professional Materials

Education materials for clients, practice guidelines and other professional tools and resources can be
found under the Related Tools & Resources tab. Use the Audience, Country and Language sort tabs to
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Additional Information

References

1. Wagner S, Breiteneder H. The latex-fruit syndrome. Biochem Soc Trans. 2002 Nov;30
(Pt6):935-40. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/12440950

This toolkit provides an overview of practice recommendations and other relevant information contained in
Practice Questions and Backgrounds in PEN® Knowledge Pathways. To view the key practice points and
other relevant information (including the associated references) see the Food Allergies - Latex-Food
Syndrome Knowledge Pathway.

In addition, the source of the NCPT used in this toolkit is: The Academy of Nutrition and Dietetics. eNCPT:
Nutrition Terminology Reference Manual. 2018. Available from: Nutrition Care Process and Terminology
Web Links.

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