Food allergy. Part 2: Diagnosis and management,☆☆

https://doi.org/10.1016/S0091-6749(99)70167-3Get rights and content

Abstract

Patients with food-induced allergic disorders may be first seen with a variety of symptoms affecting the skin, respiratory tract, gastrointestinal tract, and/or cardiovascular system. The skin and respiratory tract are most often affected by IgE-mediated food-induced allergic reactions, whereas isolated gastrointestinal disorders are most often caused by non-IgE-mediated reactions. When evaluating possible food-induced allergic disorders, it is often useful to categorize disorders into IgE- and non-IgE-mediated syndromes. The initial history and physical examination are essentially identical for IgE- and non-IgE-mediated disorders, but the subsequent evaluation differs substantially. Proper diagnoses often require screening tests for evidence of food-specific IgE and proof of reactivity through elimination diets and oral food challenges. Once properly diagnosed, strict avoidance of the implicated food or foods is the only proven form of treatment. Clinical tolerance to food allergens will develop in many patients over time, and therefore follow-up food challenges are often indicated. However, a number of novel immunomodulatory strategies are in the developmental stage and should provide more definitive treatment for some of these food-induced allergic disorders in the next several years. (J Allergy Clin Immunol 1999;103:981-9.)

Section snippets

DIAGNOSING ADVERSE FOOD REACTIONS

The diagnostic approach to suspected adverse food reactions begins with the medical history and physical examination. The goal of this exercise is to determine whether the patient is likely to have experienced an adverse reaction to food and whether it is likely to involve an immunologic (allergic) mechanism. If an allergic mechanism is suspected, it is useful to categorize reactions mechanistically (ie, IgE-mediated or non-IgE-mediated) because subsequent laboratory evaluations and oral

THERAPY FOR FOOD-INDUCED ALLERGIC DISORDERS

Once the diagnosis of food hypersensitivity is established, the only proven therapy is strict elimination of the offending allergen. Prescribing therapeutic elimination diets should be undertaken with the same consideration given to prescribing medications; both may result in unwanted side effects. Elimination diets may lead to malnutrition and/or eating disorders, especially if they include a large number of foods and/or are used for extended periods of time.44, 45 Patients and their families

NATURAL HISTORY OF FOOD HYPERSENSITIVITY

The prevalence of food hypersensitivity is greatest in the first few years of life, affecting about 6% to 8% of infants in the first year.74 Most young children “outgrow” (become tolerant of) their food hypersensitivity within a few years, except in most cases of peanut, tree nut, and seafood allergy. In a prospective study of adverse reactions to foods in infants, 80% of confirmed symptoms developed in the first year of life.74 In a prospective study of milk hypersensitivity in children

CONCLUSION

About 2% of the population is affected by various food-induced allergic disorders. A number of well-characterized food-induced allergic disorders have been delineated. Patients afflicted with these disorders may be accurately diagnosed by using a systematic evaluation, including medical history, laboratory studies, diagnostic elimination diets, and food challenges. Once the appropriate diagnosis has been made, patients must be educated to avoid the specific food allergen or allergens and to

References (81)

  • HA Sampson

    Comparative study of commercial food antigen extracts for the diagnosis of food hypersensitivity

    J Allergy Clin Immunol

    (1988)
  • FM Atkins et al.

    Evaluation of immediate adverse reactions to foods in adult patients. I. Correlation of demographic, laboratory, and prick skin test data with response to controlled oral food challenges

    J Allergy Clin Immunol

    (1985)
  • C Ortolani et al.

    Comparison of results of skin prick tests (with fresh foods and commercial food extracts) and RAST in 100 patients with oral allergy syndrome

    J Allergy Clin Immunol

    (1989)
  • E Pastorello et al.

    Allergenic cross-reactivity among peach, apricot, plum, and cherry in patients with oral allergy syndrome: an in vivo and in vitro study

    J Allergy Clin Immunol

    (1994)
  • J Menardo et al.

    Skin test reactivity in infancy

    J Allergy Clin Immunol

    (1985)
  • J Rosen et al.

    Skin testing with natural foods in patients suspected of having food allergies...is it necessary?

    J Allergy Clin Immunol

    (1994)
  • H Sampson et al.

    Relationship between food-specific IgE concentration and the risk of positive food challenges in children and adolescents

    J Allergy Clin Immunol

    (1997)
  • K-U Min et al.

    Eosinophilic gastroenteritis

    Immunol Allergy Clin North Am

    (1991)
  • KJ Kelly et al.

    Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino-acid based formula

    Gastroenterology

    (1995)
  • HA Sampson

    The role of food allergy and mediator release in atopic dermatitis

    J Allergy Clin Immunol

    (1988)
  • SH Sicherer et al.

    Clinical features of food protein-induced enterocolitis syndrome

    J Pediatr

    (1998)
  • SA Bock et al.

    The natural history of peanut allergy

    J Allergy Clin Immunol

    (1989)
  • J Bernhisel-Broadbent et al.

    Fish hypersensitivity. I. In vitro and oral challenge results in fish-allergic patients

    J Allergy Clin Immunol

    (1992)
  • S Werfel et al.

    Clinical reactivity to beef in cow milk allergic children

    J Allergy Clin Immunol

    (1997)
  • HA Sampson et al.

    Natural history of food hypersensitivity in children with atopic dermatitis

    J Pediatr

    (1989)
  • AW Burks et al.

    Double-blind placebo-controlled trial of oral cromolyn in children with atopic dermatitis and documented food hypersensitivity

    J Allergy Clin Immunol

    (1988)
  • SH Sicherer et al.

    Prevalence of peanut and tree nut allergy in the US as determined by a random digit dial telephone survey

    J Allergy Clin Immunol

    (1999)
  • JJ Oppenheimer et al.

    Treatment of peanut allergy with rush immunotherapy

    J Allergy Clin Immunol

    (1992)
  • HS Nelson et al.

    Treatment of anaphylactic sensitivity to peanuts by immunotherapy with injections of aqueous peanut extract

    J Allergy Clin Immunol

    (1997)
  • PA Eigenmann et al.

    Identification of unique peanut and soy allergens in sera adsorbed with cross-reacting antibodies

    J Allergy Clin Immunol

    (1996)
  • D Shin et al.

    Identification and analysis of the critical amino acids and structures necessary for specific IgE binding to Ara h 1, a major peanut allergen

    J Biol Chem

    (1998)
  • JS Stanley et al.

    Identification and mutational analysis of the immunodominant IgE binding epitopes of the major peanut allergen Ara h 2

    Arch Biochem Biophys

    (1997)
  • SA Bock

    The natural history of food sensitivity

    J Allergy Clin Immunol

    (1982)
  • DJ Hill et al.

    Recovery from milk allergy in early childhood: antibody study

    J Pediatr

    (1989)
  • AW Burks et al.

    Atopic dermatitis and food hypersensitivity reactions

    J Pediatr

    (1998)
  • DJ Hill et al.

    Manifestations of milk allergy in infancy: clinical and immunological findings

    J Pediatr

    (1986)
  • SA Bock et al.

    Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual

    J Allergy Clin Immunol

    (1988)
  • SH Sicherer

    Manifestations of food allergy: evaluation and management

    Am Fam Physician

    (1999)
  • HA Sampson

    Immunologically mediated food allergy: the importance of food challenge procedures

    Ann Allergy

    (1988)
  • AW Burks et al.

    Atopic dermatitis: clinical relevance of food hypersensitivity reactions

    J Pediatr

    (1988)
  • Cited by (486)

    • Skin prick testing for foods

      2022, Allergic and Immunologic Diseases: A Practical Guide to the Evaluation, Diagnosis and Management of Allergic and Immunologic Diseases
    • Tackling Food Allergy in Infancy

      2021, Immunology and Allergy Clinics of North America
    • Rhinitis 2020: A practice parameter update

      2020, Journal of Allergy and Clinical Immunology
    • Oral Food Challenges in Infants and Toddlers

      2019, Immunology and Allergy Clinics of North America
    View all citing articles on Scopus

    Reprint requests: Hugh A. Sampson, MD, Department of Pediatrics, Box 1198, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029-6574.

    ☆☆

    0091-6749/99 $8.00 + 0  1/1/98507

    View full text