Food Allergy IPACI 2022
Food Allergy IPACI 2022
Food Allergy IPACI 2022
Endah Citraresmi
Allergy Immunology Working Group – Indonesian Pediatric Society
Harapan Kita Women & Children Hospital, Jakarta, Indonesia
Pointers
Supporting
Epidemiology Manifestation Diagnosis Management
Test
Definition
• A food allergy is defined as an adverse health effect arising from a
specific immune response that occurs reproducibly on exposure to a
given food
“Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of
the NIAID-Sponsored Expert Panel.” Journal of Allergy and Clinical Immunology 126, no. 6
(December 2010): S1–58.
Epidemiology
• The prevalence of IgE-mediated
food allergy in the population varies
between 2% and 10%
• Food allergy is greater in the
pediatric population than in adults,
with estimates of 6% to 8% in
children under 5 years and 3% to
4% in adults
• Different methods: self-reported vs
sensitization vs confirmed by
DBPCFC
• Recently emerging as a ‘second
wave’ of the allergy epidemic
J Allergy Clin Immunol. 2014;134:1016-25.e43; JAMA. 2010;303:1848-56;
Nat Rev Dis Primers 2018;4:17098
Food Allergy: Mechanism
Gastroenterology
2015;148:1120–1131
Food Allergy Classification
Based on the immunological mechanism involved
Mixed IgE
IgE- Cell mediated-
mediated mediated When the cell component of
the immune system is
cell
responsible of the food allergy mediated
and mostly involve the
Mediated by antibodies gastrointestinal tract
belonging to the
Immunoglobulin E (IgE). The Hours – days after ingestion
best-characterized food allergy Food protein induced When both IgE and immune
reactions enteropathy (FPIE): diarrhea, cells are involved in the
mild to moderate steatorrhea reaction
<1 hour after ingestion
(80% of cases) & poor weight EGIDS (Eosinophilic
Skin: Urticaria, angioedema gain Gastrointestinal Disorders):
GIT: Vomiting, diarrhea, colic Food protein-induced Allergic eosinophilic esophagitis,
Proctocolitis (FPIAP): rectal gastritis, gastroenteritis, colitis
Respiratory manifestations
(asthma or allergic rhinitis): bleeding, well & thriving Acute flare-up of atopic
infrequent, especially as infants eczema
isolated symptoms Food protein-induced
Most severe form: anaphylaxis enterocolitis syndrome
(FPIES): immediate-onset,
repeated vomiting episodes,
sometimes leading to
dehydration
IgE-mediated-food allergy
Journal of Allergy and Clinical Immunology 126, no. 6 (December 2010): S1–58.
Cutaneous Manifestations
IgE-mediated
• Immediate gastrointestinal hypersensitivity (e.g. nausea, vomiting, diarrhea)
• Oral allergy syndrome
Non-IgE-mediated
• Allergic eosinophilic esophagitis, gastritis or gastroenterocolitis
• Food protein-induced enterocolitis syndrome (FPIES)
• Food protein-induced allergic proctocolitis (FPIAP)
• Food protein-induced enteropathy (FPE)
Clinical characteristics of non-IgE-mediated
gastrointestinal food allergies
FPIES FPIAP FPE
Typical age of onset Days to 1 year Days to 6 months 2-24 months
Symptoms
Emesis Prominent No Intermittent
Diarrhea Severe No Moderate
Bloody stools Severe Moderate Rare
Edema Acute, severe No Moderate
Shock 15-20% No No
Failure to thrive Moderate No Moderate
Allergy Asthma Clin Immunol 2018, 14(Suppl 2):56. Pediatr Allergy Immunol 2017: 28: 6–17.
Infections
Other
allergic
disorders
GI disorders
Others
Differential Diagnosis
Pediatr Allergy Immunol 2017: 28: 6–17.
Eosinophilic GI disorders (EGIDs)
• A group of inflammatory disorders primarily classified by the
presence of a high density of infiltrating eosinophils within the GI
mucosal epithelium, muscularis, and serosal layers
• Include eosinophilic esophagitis (EoE), eosinophilic gastroenteritis
(EG), and eosinophilic colitis (EC)
Cows'
milk
Hen's
eggs
Wheat
J Allergy Clin Immunol 2012;129:906-20
Oral allergy syndrome (or pollen-food
syndrome)
Clin Exp Allergy 2013;43:1333-1341; J Allergy Clin Immunol 2010;126:S1-S58; Allergy 2014;69:1046-1057; Pediatr Allergy Immunol 2018; 29:689-704
Prognosis
• The prognosis of food allergy depends on the person's age, co-morbidities, and
specific causal food allergen.
• Most children outgrow their food allergy over time: cow’s milk, egg, wheat, soy
• Certain food allergies are most likely to persist, such as peanuts, tree nuts, fish,
and shellfish
• Factors which may increase the likelihood of severe food allergy and/or
anaphylaxis include:
• A history of asthma, especially if it is poorly controlled
• A history of other atopic disease, such as atopic eczema or allergic rhinitis.
• A history of previous systemic allergic reaction.
• Allergy to the food classes of peanut, tree nut, fish, or shellfish
• Epicutaneous introduction of allergen extracts • Widely available, but results are not
with a lancet, typically to the volar aspect of immediate and may take days to weeks to
the forearm process
• The site is inspected after 15 minutes and
compared with positive and negative controls
(observer dependent), to detect sensitization
to allergens
[RCPCH, 2011; Burks, 2012; Longo, 2013; Steele, 2014; Turnbull, 2015; Stiefel, 2017; NICE, 2018]
Allergy testing: sensitization vs true allergy
Allergy testing cannot distinguish between sensitization and true allergy, so test results must be
interpreted in the context of the clinical history
• Some people have positive test results but do not develop symptoms of clinical allergy on exposure to the
relevant food allergen (food sensitization only and a false positive result)
• Due to the poor specificity of tests, indiscriminately testing for large panels of food allergens is not
recommended as there is a high false positive rate.
• Some people may have a strong clinical history of IgE-mediated food allergy but negative allergy test
results (false negative result)
Increased size of the skin prick wheal or concentrations of serum-specific IgE are associated with
an increased likelihood of food allergy, but they do not predict symptom severity
• Ideally raw foods should be used in skin prick testing for the assessment of suspected oral allergy
syndrome
Predictive Value of Food Specific IgE
Allergen Decision Point Rechallenge Value
(kUA/L) (kUA/L)
Egg ≥ 7.0 ≤ 1.5
≤2 years old ≥ 2.0
Milk ≥ 15.0 ≤ 7.0
≤2 years old ≥ 5.0
Peanut ≥ 14.0 ≤ 5.0
Fish ≥ 20.0
Tree nuts ≥ 15.0 <2
J Allergy Clin Immunol. 2001; 107: 891–896
Assessing tolerance
• Allergy testing may also be used to assess whether tolerance has
developed in a person with a confirmed food allergy. The optimal
interval for follow-up testing is not known, and partly depends on the
specific food allergen:
• For egg, soybean, or wheat allergy, testing every 12–18 months up to the age
of 5 years, and every 2–3 years following this, may be recommended.
• For peanut, tree nut, fish, and shellfish allergy, testing every 2–4 years may be
recommended.
[RCPCH, 2011; Burks, 2012; Longo, 2013; Steele, 2014; Turnbull, 2015; Stiefel, 2017; NICE, 2018]
Oral Food Challenge
• If the results of allergy testing do not correspond with the clinical
history, an oral food challenge may be needed to confirm the
diagnosis
• Oral food challenge is the gold standard for diagnosis of
food allergy, and is an accurate and sensitive test
• It involves the administration of increasing quantities of the
food allergen under medical supervision, starting with direct
mucosal exposure (allergen contact with the lips) and then
titrated oral ingestion as tolerated
• If symptoms are not provoked, the test is negative and
clinical allergy can be excluded
• If there has been a previous severe reaction to a known
food, a repeat challenge is not usually arranged for at least
two years
https://www.foodallergy.org/resources/oral-food-challenge
Oral Food Challenge
• Types of oral food challenge:
• Double-Blind Placebo-Controlled Food Challenge
• Single-Blind Placebo-Controlled Food Challenge
• Open Oral Food Challenge → objective symptoms, infants
• Location of food challenge:
• Clinical settings
• Home challenge → mild/moderate reactions, not life threatening, non-IgE-
mediated
Investigational studies
• Atopy patch testing - identify allergens that cause reactions through
delayed contact hypersensitivity where T-cells play a major role. Allergenic
extract is occluded against intact skin for 48 hours; it is available for
investigational use only
• Patch testing is well validated for contact dermatitis but not food allergy in general
• Purified or recombinant allergens - identify specific IgE sensitisation to
proteins within an individual food allergen in component-resolved
diagnostics
• Some studies have shown an increased ability to predict the likelihood of having a
severe allergic reaction to foods like peanut, soy, or hazelnut; however, geographical
pollen sensitisation patterns may affect results, and further studies are needed to
generalise interpretability
Allergen Components
Hypoallergenic Formula
Tolerated by 90% of children with
CMPA
• Extensively hydrolyzed formula
(EHF), which contains short
peptides (most below 1500 Da)
• Amino acid formula (AAF), which
provides protein in the form of
amino acids
Arch Dis Child 1999;81:80-4
J Allergy Clin Immunol Pract 2018;6:383-99
Pediatric Formula Recommendations
Based on DRACMA Guidelines
Food Allergy Symptom or Disorder 1st Choice 2nd Choice 3rd Choice
IgE-mediated allergy eHF AAF SF
Low risk anaphylaxis
IgE-mediated allergy AAF eHF SF
High risk anaphylaxis
FPIES AAF eHF -
Eosinophilic esophagitis AAF - -
Heiner syndrome AAF SF eHF
Other Non-IgE-mediated: GERD, eHF AAF
enteropathy, constipation, colic,
gastroenteritis & proctocolitis, atopic
dermatitis
eHF: extensively hydrolyzed formula; AAF: amino acid formula; SF: soy formula
https://gpifn.files.wordpress.com/2019/10/imap
_final_ladder-may_2017_original.pdf
Egg Ladder
https://www.ifan.ie/egg/egg-classification-ladder/
Education
Signs &
School & Importance symptoms of
Reading food
eating out of avoidance food allergy,
label
preparation adherence emergency &
management
Reading food
label
Reading Food Label
Eating out:
Avoid cross-contamination
Food Allergy Reactions & How to Manage
Growth Monitoring
• Growth disorders can occur:
• Due to an allergic reaction that has
occurred: gastrointestinal symptoms
(vomiting, diarrhea, refusal to
breastfeed), severe atopic dermatitis
• Consequences of avoiding cow's milk
from the diet: difficult to choose
food
• It is important to monitor growth
to prevent growth disorders →
involve nutritionist
Follow Up: Tolerance Evaluation
Toit, George du, Teresa Tsakok, Simon Lack, and Gideon Lack. “Prevention of Food Allergy.” Journal of Allergy and Clinical Immunology 137, no. 4 (April 2016): 998–1010.
Early Introduction of Allergenic Foods
• RCTs: early introduction of allergenic foods (peanut/egg) to high-risk
infants with severe AD or pre-existing food sensitization may reduce the
risk of developing peanut or egg allergies
The Prevention of Egg allergy with Tiny amount
Learning Early About Peanut Allergy (LEAP) study
InTake (PETIT) study
• Highrisk infants aged 4-11 months with severe AD • Investigated the effects of early introduction of
and/or egg allergy and peanut skin prick test (SPT) heated egg powder to high-risk Japanese infants
responses of 1-4 mm with AD on the development of egg allergy
• Infants randomized to consume 6 grams of peanut • The intervention group which received 50 mg of
protein at least 3 times a week or 2 grams 3 times heated whole egg powder between 6-9 months of
a week had an 81.4% lower risk of developing age, then 250 mg between 9-12 months of age,
challenge-proven peanut allergy by age 5 years, had 30% lower risk of developing challenge-
compared to those who completely avoided proven hen's egg allergy at 12 months of age,
peanut products compared to the placebo group
Natsume O, Kabashima S, Nakazato J, Yamamoto-Hanada K, Narita M, Kondo M, et al. Two-step egg
Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of
introduction for prevention of egg allergy in high-risk infants with eczema (PETIT): a randomised,
peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015;372:803-13
double-blind, placebo-controlled trial. Lancet 2017;389:276-86.