Food allergy

Adverse reactions to foods

Food allergy Food intolerance Toxins Bacterial toxins Aflatoxins Scombroid poisoning

Toxic reactions Non-immune mediated Immune mediated

Mixed IgE- and non-IgE-mediated

Pharmacological caffeine tyramine

Enzyme deficiencies lactose/ fructose malabsorption

Non-specific • IBS • Functional disoredres of GI

tract

Non-IgEmediated

IgE-mediated

Coeliac Disease

Uncleare Pathophysiology explained

Food allergy - prevalence

• 1-2% of population

• Anaphylaxis to food ( 0-19 years)

22 per 100 000 person years (food allergy - 50 000 anaphylactic reaction /year in USA)

Adverse reactions to food

Non-immune mediated Immune mediated (Food allergy, celiac disease)

IgE-mediated Non-IgE mediated

Food allergens

Children Adults

Milk Eggs Wheat Soy Tree nuts Peanuts

Tree nuts Peanuts Fish Shelfish

Most frequent symptoms of mild to moderate CMPA

Therapeutic area Symptoms

Gastrointestinal Frequent regurgitation Vomiting Diarrhea Constipationa Blood in stool without failure to thrive

Dermatological Atopic dermatitis Swelling of lips or eye lids Urticaria unrelated to acute infections, drug intake, or other causes

Respiratory Runny nose Recurrent otitis media Chronic cough Broncho-constriction unrelated to infection

General Persistent distress Colic (≥3 h/day wailing/irritable) over a period of >3 weeks

Remember!

Different clinical patterns of food allergy may combine in the same patient.

Phenotypes of food allergy

Transient

Persistent (IgE-dependent)

Pollen – food syndome

(Oral allergy syndrome)

Allergic march

GI tract food allergy

Atopic dermatitis

Eosinophilic esophagitis

Asthma

Poród 0,5 1 3 ? 18 wiek

Food allergens

Airborn allergens

Rhinitis

It is hard to predict how one child with

allergy will experience this progression

compared to another.

• Pruritis

• Urticaria

• Angioedema

• Vomiting

• Diarrhea

• ANAPHYLAXIS

Acute Delayed

Minutes Hours

• Allergic proctocolitis • FPIES (food protein induced enterocolitis

syndrome) • Food proteine induced eneropathy

Eosinophilic IG tract disorders AD

IgE-mediated food allergy

Reproducible

Typical symptoms

Acute

Positive tests

Non-IgE-mediated food allergy

• Ingested food and their ingredients • Description of symptoms • Timing of onset of symptoms • Quantity of food to produce symptoms • Frequency of reactions and reproducibility • Most recent occurrence • Accompanying factors (e.g., exercise,

intake of other foods, drugs, coffee, alcohol, infections, stress, etc.)

• Diary reporting symptoms and food intake

Case history

• Determination of total lgE • Determination of specific lgE antibodies to food

allergen extracts • Component-resolved allergy diagnosis with single

food allergens or in multiplex assays • lgE immunoblots or lgE ELISA with allergy-causing

food extract

• Basophil activation test • Direct basophil activation • Histamine release • Leukotriene release • CD63, CD203c, upregulation

• Passive basophil activation tests • T cell proliferation assays • Cytokine secretion assays

In vitro assays

• Skin prick test (SPT) • "Prick-prick" test • Intradermal skin test • Atopy patch test

• Baseline registration of symptoms • Diet period

• Open oral challenge with native foods/-additives

• Single or double-blind oral challenge with selected foods

• lntragastral provocation under endoscopic control (IPEC)

• Colonoscopic allergen provocation test (COLAP)

Skin tests

Elimination/ reinroduction diets

Provocation tests

Diagnosis

• Skin prick tests (SPT) (native, commerciale)

Diagnosis

• Atopy patch tests

Case history

Identification of the

disease-causing allergens

In vitro assays Skin tests

Elimination/ reinroduction

diets

Provocation tests

Management of lgE-associated food allergy • Allergen-specific: avoidance diet • Allergen-specific: immunotherapy (SIT)

Unspecific: • Symptomatic medication • (antihistamines, antileukotrienes, steroids,

epinephrine) • Anti-lgE treatment

History Elimination diet

Final diagnosis

Treatment

• Strict dietary avoidance of the offending food

• Nutritional planning: dietitian

• Use of self-injectable epinephrine in case of accidental

exposure with allergic reaction

• Monitoring (nutritional status, antropometry)

• Oral food challenge: tolerance?

Treatment

Many individuals will eventually outgrow their food allergies, a substantial number will not.

• Protection from food-triggered reactions

• Immune-modulating therapies (development of tolerance) – oral immunotherapy

– sublingual immunotherapy

– epicutaneous immunotherapy.

Cow milk protein allergy (CMPA)

? CMPA based on symptoms? +/- specyfic IgE/ SPT

Formula fed baby Anaphlaxis

(spec IgE positive or pos SPT)

Formula fed baby No anapyhylaxis

Breastfed baby

Continue BF, mother on CM-free diet For 2-4 weeks

2-4 weeks AAF EHF 2-4 weeks

(soy or eRHF if eHF not accepted)

Symptoms improve or disappear Symptoms improve or disappear Symptoms improve or disappear

No Yes No Yes No Yes

Not CMPA Not CMPA Reconsider compilance Consult dietician & medical

specialist Not CMPA? Consider Cow’s milk challenge

May not be undertaken if clinical diagnosis is obvious or symptoms are life threatening

Long-term management Elimination of cow milk sources

Consider: Breast milk as the first option Extensively hydrolyzed formula (CM/Rice)/ Soy formula / AAF

For at least 6 months or until 9 to 12 months of age Monitor for tolerance

SPT: skin prick test BF: breastfeeding AAF: amini acid based formula E(R)HF: extensive (rice) hydrolysate formula

Food Allergy Action Plan Emergency Care Plan

Name: DOB: 10/2/2014 Allergy to: *** Weight: kg Asthma: yes no Childis Extremely reactive to the following foods: THEREFORE: [ ] If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten. [ ] If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted

Any SEVERE SYMPTOMS after suspected or known

ingestions.

OR one or more of the following:

Lung: Short of breath, wheeze, repetitive cough

Heart:Pale, blue, faint, weak pulse, dizzy, confused

Throat:Tight, hoarse, trouble breathing/swallowing

Mouth: Obstructive swelling (tongue and/or lips)

Skin: Many hives over body

OR combination of symptoms from different body

areas:

Skin: Hives, itchy rashes, swelling (e.g., eyes, lips)

Gut: Vomiting, diarrhea, crampy pain

1. INJECT EPINEPHRINE IMMEDIATELY

2. Call 911

3. Begin monitoring (see box below)

4. Give additional medications:*

- Antihistamine

- Inhaler (bronchodilator) if asthma

*Antihistamines & inhalers/bronchodilators

are not to be depended upon to treat a

severe reaction (anaphylaxis). USE

EPINEPHRINE.

MILD SYMPTOMS ONLY:

Mouth:Itchy mouth

Skin: A few hives around mouth/face, mild itch

Gut: Mild nausea/ discomfort

1. GIVE ANTIHISTAMINE

2. Stay with student: alert healthcare

professionals and parent.

3. If symptoms progress (see above), USE

EPINEPHRINE

4. Begin monitoring (see box below)

Medications/Doses

Epinephrine (brand and dose):

Antihistamine (brand and dose): Additional Contact Information:

Parent's Name (other contacts) and Contact Numbers

DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN IF PARENTS CAN NOT BE REACHED!!

Monitoring: Stay with child; alert healthcare professionals and parents. Tell rescue squad epinephrine was given;

request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of

epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction,

consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See

back/ attached for auto-injection technique.

Nearest Hospital: Phone: Address:

Allergist Name: Phone:

Pediatrician Name: Phone:

Name: Phone: Phone #2:

Name: Phone: Phone #2:

Date Parent's Signature Date

Additional Contact Information:

Parent's Name (other contacts) and Contact Numbers

DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN IF PARENTS CAN NOT BE REACHED!!

Chronic Acute

Intermittent vomiting

Chronic diarrhea

(blood and mucous)

Letarghy

Pallor

Abdominal distention

Dehydration

Weight loss

Failure to thrive

Repetitive vomiting

(1-3 h after digestion)

Diarrhea (5 h after digestion)

Wzdęcie brzucha

Letarghy

Pallor

Dehydration

Hypotension

Hypothermia

FPIES

Food protein induced enterocolitis syndrome

Infants

Young children

milk

soy

rice

owies, pszenica, jęczmień, żyto

eggs

green peas

chicken, turkey, fish

Adolescents

Adults

Fish

Shelfish

FPIES - allergens

Chronic Acute

Anemia

Hipoalbuminemia

Neutrophilia

Eozynofilia

Metabolic acidosis

Methemoglobulinemia

Neutrophilia

Thrombocytosis

Metabolic acidosis

Methemoglobulinemia

Blood in stool

IgE spec (-) (+)

APT (-) (+)

FPIES laboratory tests

Treatment of acute FPIES (wg Nowak-Węgrzyn)

Fluids

Methylprednizolone

Ondansetron

20 ml/kg . 0,9% NaCl IV in 10 min

1 mg/kg. (max 60 mg) dożylnie

0,2 mg/kg IV

• A common cause of rectal bleeding in an otherwise healthy young infant.

• In exclusively breast fed or formula supplemented or fed infants .

• It is characterized by inflammation of the distal colon in response to one or more food proteins, through a mechanism that does not involve immunoglobulin E (IgE).

• Cow's milk and soy protein are common triggers. • A diagnosis of allergic colitis (1)characterized clinically by rectal bleeding; (2) exclusion of infectious causes of colitis (3) disappearance of symptoms after elimination of cow’s milk and dairy products from the child’s and/or the mother’s diet. • In most cases resolves by late infancy.

Allergic proctocolitis

Patient with blood streaked stool

Medical history Patient's age General condition Physical examination

3–8 week old infant Good general condition Mild bleeding Exclusively breast feeding Cows' milk protein in mother's diet

Tentative diagnosis: Begin eosinophilic proctocolitis Hypoalbuminaemia

Red blood cell count Peripheral eosinophilia

Restriction of cows' milk protein from mother's diet

Resolution of bleeding within 72–96 hours

Progressive bleeding Re-evaluation Proto colonoscopy Biopsy

The elemental amino acid-based formula