Reviews and feature articles
Update on food allergy

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Abstract

Tremendous progress has been made in our understanding of food-based allergic disorders over the past 5 years. Recent epidemiologic studies suggest that nearly 4% of Americans are afflicted with food allergies, a prevalence much higher than appreciated in the past. In addition, the prevalence of peanut allergy was found to have doubled in American children less than 5 years of age in the past 5 years. Many food allergens have been characterized at the molecular level, which has contributed to our increased understanding of the immunopathogenesis of many allergic disorders and might soon lead to novel diagnostic and immunotherapeutic approaches. The management of food allergies continues to consist of educating patients on how to avoid relevant allergens, to recognize early symptoms of an allergic reaction in case of an accidental ingestion, and to initiate the appropriate emergency therapy. However, the recent successful clinical trial of anti-IgE therapy in patients with peanut allergy and the number of immunomodulatory therapies in the pipeline provide real hope that we will soon be able to treat patients with food allergy.

Section snippets

Immunopathogenesis and clinical disorders

In the 5 years since the Journal's previous review on food allergy,1., 2. our understanding of food-induced allergic reactions has increased dramatically, especially in the area of diagnosis and management. Investigation of allergenic food proteins and immunologic responses has moved to the molecular level, and this newfound knowledge now provides novel strategies for the laboratory diagnosis and immunomodulatory control of IgE-mediated food hypersensitivity. Food allergy is now recognized as a

Prevalence of food hypersensitivity

The prevalence of food hypersensitivities is greatest in the first few years of life, affecting about 6% of infants less than 3 years of age5 and decreasing over the first decade. Virtually all infants who have cow's milk allergy have it in the first year of life, with clinical tolerance developing in about 80% by their fifth birthday.1 About 60% of infants with cow's milk allergy experience IgE-mediated reactions, and about 25% of these infants retain their sensitivity into the second decade

Gut barrier

Food allergy represents an abnormal response of the mucosal immune system to antigens delivered through the oral route. Unlike the systemic immune system, which sees relatively small quantities of antigen and mounts a brisk inflammatory response, the mucosal immune system encounters enormous quantities of antigen on a daily basis and generally suppresses immune reactivity to harmless foreign antigens (eg, food proteins and commensal organisms), although it is fully capable of mounting a brisk

Clinical disorders

Food hypersensitivities develop in genetically predisposed individuals,34 presumably when oral tolerance fails to develop normally or breaks down. IgE-mediated reactions develop when food-specific IgE antibodies residing on mast cells and basophils come in contact with and bind circulating food allergens and activate the cells to release potent mediators and cytokines. As depicted in Table II, a number of IgE-, cellular-, and mixed IgE– and cell-mediated food hypersensitivity disorders have

Diagnosing adverse food reactions

The approach to diagnosing adverse food reactions has changed little over the past 5 years,2 as recently reviewed,89., 90. although new laboratory approaches are proving useful for the diagnosis of IgE-mediated food allergy. The medical history continues to be a mainstay in the diagnostic process, attempting to establish whether a food-induced allergic reaction occurred, which food was involved, and what allergic mechanism was likely involved. Diet diaries can be a useful supplement to a

References (160)

  • S.J Maleki et al.

    The major peanut allergen, Ara h 2, functions as a trypsin inhibitor, and roasting enhances this function

    J Allergy Clin Immunol

    (2003)
  • H Breiteneder et al.

    Molecular and biochemical classification of plant-derived food allergens

    J Allergy Clin Immunol

    (2000)
  • H Breiteneder et al.

    J Allergy Clin Immunol

    (2004)
  • S.H Sicherer et al.

    Genetics of peanut allergy: a twin study

    J Allergy Clin Immunol

    (2000)
  • H.A Sampson et al.

    AGA technical review on the evaluation of food allergy in gastrointestinal disorders. American Gastroenterological Association

    Gastroenterology

    (2001)
  • M.E Rothenberg et al.

    Pathogenesis and clinical features of eosinophilic esophagitis

    J Allergy Clin Immunol

    (2001)
  • K.J Kelly et al.

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

    Gastroenterology

    (1995)
  • S.R Orenstein et al.

    The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children

    Am J Gastroenterol

    (2000)
  • J.W Potter et al.

    Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features

    Gastrointest Endosc

    (2004)
  • M.E Rothenberg

    Eosinophilic gastrointestinal disorders (EGID)

    J Allergy Clin Immunol

    (2004)
  • A Mishra et al.

    Intratracheal IL-13 induces eosinophilic esophagitis by an IL-5, eotaxin-1, and STAT6-dependent mechanism

    J Clin Invest

    (2003)
  • X.M Li et al.

    A murine model of IgE-mediated cow's milk hypersensitivity

    J Allergy Clin Immunol

    (1999)
  • X.M Li et al.

    A murine model of peanut anaphylaxis: T- and B-cell responses to a major peanut allergen mimic human responses

    J Allergy Clin Immunol

    (2000)
  • E Untersmayr et al.

    Antacid medication inhibits digestion of dietary proteins and causes food allergy: a fish allergy model in BALB/c mice

    J Allergy Clin Immunol

    (2003)
  • K Beyer et al.

    Human milk-specific mucosal lymphocytes of the gastrointestinal tract display a TH2 cytokine profile

    J Allergy Clin Immunol

    (2002)
  • S.H Sicherer et al.

    Clinical features of food protein-induced enterocolitis syndrome

    J Pediatr

    (1998)
  • L.M Sollid et al.

    HLA susceptibility genes in celiac disease: genetic mapping and role in pathogenesis

    Gastroenterology

    (1993)
  • M.W Greaves

    Chronic urticaria

    J Allergy Clin Immunol

    (2000)
  • T Bieber et al.

    New insights in the structure and biology of the high affinity receptor for IgE (Fc episilon RI) on human epidermal Langerhans cells

    J Dermatol Sci

    (1996)
  • X.M Li et al.

    Murine model of atopic dermatitis associated with food hypersensitivity

    J Allergy Clin Immunol

    (2001)
  • G Roberts et al.

    Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study

    J Allergy Clin Immunol

    (2003)
  • S.H Sicherer et al.

    Self-reported allergic reactions to peanut on commercial airliners

    J Allergy Clin Immunol

    (1999)
  • S.J Simonte et al.

    Relevance of casual contact with peanut butter in children with peanut allergy

    J Allergy Clin Immunol

    (2003)
  • S.K Lee et al.

    Cow's milk-induced pulmonary disease in children

    Adv Pediatr

    (1978)
  • S.A Bock et al.

    Fatalities due to anaphylactic reactions to foods

    J Allergy Clin Immunol

    (2001)
  • R.Y Lin et al.

    Histamine and tryptase levels in patients with acute allergic reactions: an emergency department-based study

    J Allergy Clin Immunol

    (2000)
  • R Horan et al.

    Food-dependent exercise-induced anaphylaxis

    Immunol Allergy Clin North Am

    (1991)
  • K Palosuo et al.

    A novel wheat gliadin as a cause of exercise-induced anaphylaxis

    J Allergy Clin Immunol

    (1999)
  • K Palosuo et al.

    Transglutaminase-mediated cross-linking of a peptic fraction of omega-5 gliadin enhances IgE reactivity in wheat-dependent, exercise-induced anaphylaxis

    J Allergy Clin Immunol

    (2003)
  • S.H Sicherer

    Food allergy

    Lancet

    (2002)
  • 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)
  • B Niggemann et al.

    Predictors of positive food challenge outcome in non-IgE-mediated reactions to food in children with atopic dermatitis

    J Allergy Clin Immunol

    (2001)
  • C.C Roehr et al.

    Atopy patch tests, together with determination of specific IgE levels, reduce the need for oral food challenges in children with atopic dermatitis

    J Allergy Clin Immunol

    (2001)
  • J.M Spergel et al.

    The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis

    J Allergy Clin Immunol

    (2002)
  • 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)
  • H.A Sampson

    Food AllergyPart 2: diagnosis and management

    J Allergy Clin Immunol

    (1999)
  • S Johansson et al.

    A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force

    Allergy

    (2001)
  • S.A Bock

    Prospective appraisal of complaints of adverse reactions to foods in children during the first 3 years of life

    Pediatrics

    (1987)
  • A Host et al.

    The natural course of cow's milk protein allergy/intolerance

    J Allergy Clin Immunol

    (1997)
  • J.O'B Hourihane et al.

    Resolution of peanut allergy: case-control study

    BMJ

    (1998)
  • Cited by (0)

    Disclosure of potential conflict of interest: H. Sampson has consultant arrangements with Seer Pharmaceuticals and receives grants/research support from Pharmacia Diagnostics.

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