Dr.Janice Joneja. Success with Food Allergy and Intolerance

SUCCESS WITH FOOD SUCCESS WITH FOOD ALLERGY AND INTOLERANCEALLERGY AND INTOLERANCE

Janice Joneja Ph.D., RDJanice Joneja Ph.D., RD

2

Food Allergy & Food Intolerance Food Allergy & Food Intolerance DEFINITIONS:DEFINITIONS:

Food Allergy

An immunologic

reaction resulting

from the ingestion

of a food or

food additive

Food Intolerance

A generic term

describing an abnormal

physiological response

to an ingested food or

food additive which is

not immunogenic

3

Symptoms of Food AllergySymptoms of Food Allergy

Controversy among practitioners because there are Controversy among practitioners because there are no definitive tests for food allergyno definitive tests for food allergy

Symptoms appear in diverse organ systems:Symptoms appear in diverse organ systems: Skin and mucous membranesSkin and mucous membranes Digestive tractDigestive tract Respiratory tractRespiratory tract Systemic (anaphylaxis)Systemic (anaphylaxis)

Symptoms in nervous system are considered more Symptoms in nervous system are considered more subjective and sometimes may be dismissed as subjective and sometimes may be dismissed as fictitious or psychosomaticfictitious or psychosomatic

4

Examples of Allergic ConditionsExamples of Allergic Conditions and Symptoms and Symptoms

Skin and Mucous MembranesSkin and Mucous Membranes Atopic dermatitis (eczema)Atopic dermatitis (eczema) Urticaria (hives)Urticaria (hives) Angioedema (swelling of tissues, especially mouth and Angioedema (swelling of tissues, especially mouth and

face)face) Pruritus (itching)Pruritus (itching) Contact dermatitis (rash in contact with allergen)Contact dermatitis (rash in contact with allergen) Oral symptoms (irritation and swelling of tissues Oral symptoms (irritation and swelling of tissues

around and inside thearound and inside the mouth)mouth) Oral allergy syndromeOral allergy syndrome

5


Digestive TractDigestive Tract DiarrheaDiarrhea ConstipationConstipation Nausea and VomitingNausea and Vomiting Abdominal bloating and distensionAbdominal bloating and distension Abdominal painAbdominal pain Indigestion (heartburn)Indigestion (heartburn) BelchingBelching

6


Respiratory TractRespiratory Tract Seasonal or perennial rhinitis (hayfever)Seasonal or perennial rhinitis (hayfever) Rhinorrhea (runny nose)Rhinorrhea (runny nose) Allergic conjunctivitis (itchy, watery, reddened eyes)Allergic conjunctivitis (itchy, watery, reddened eyes) Serous otitis media (earache with effusion) [“gum ear”; Serous otitis media (earache with effusion) [“gum ear”;

“glue ear”]“glue ear”] AsthmaAsthma Laryngeal oedema (throat tightening due to swelling of Laryngeal oedema (throat tightening due to swelling of

tissues)tissues)

7


Nervous SystemNervous System MigraineMigraine Other headachesOther headaches Spots before the eyesSpots before the eyes ListlessnessListlessness HyperactivityHyperactivity Lack of concentrationLack of concentration Tension-fatigue syndromeTension-fatigue syndrome IrritabilityIrritability ChillinessChilliness DizzinessDizziness

8


OtherOther Urinary frequencyUrinary frequency Bed-wettingBed-wetting HoarsenessHoarseness Muscle achesMuscle aches Low-grade feverLow-grade fever Excessive sweatingExcessive sweating PallorPallor Dark circles around the eyesDark circles around the eyes

9

AnaphylaxisAnaphylaxis

Severe reaction of rapid onset, involving Severe reaction of rapid onset, involving most organ systems, which results in most organ systems, which results in circulatory collapse and drop in blood circulatory collapse and drop in blood pressurepressure

In the most extreme cases the reaction In the most extreme cases the reaction progresses to anaphylactic shock with progresses to anaphylactic shock with cardiovascular collapsecardiovascular collapse

This can be fatalThis can be fatal

10

AnaphylaxisAnaphylaxis Usual progress of reactionUsual progress of reaction

Burning, itching and irritation of mouth and oral tissues Burning, itching and irritation of mouth and oral tissues and throatand throat

Nausea, vomiting, abdominal pain, diarrheaNausea, vomiting, abdominal pain, diarrhea Feeling of malaise, anxiety, generalized itching, Feeling of malaise, anxiety, generalized itching,

faintness, body feels warmfaintness, body feels warm Nasal irritation and sneezing, irritated eyesNasal irritation and sneezing, irritated eyes Hives, swelling of facial tissues, reddeningHives, swelling of facial tissues, reddening Chest tightness, bronchospasm, hoarsenessChest tightness, bronchospasm, hoarseness Pulse is rapid, weak, irregular, difficult to detectPulse is rapid, weak, irregular, difficult to detect Loss of consciousnessLoss of consciousness Death may result from suffocation, cardiac arrhythmia, Death may result from suffocation, cardiac arrhythmia,

or shockor shock

11

Foods and AnaphylaxisFoods and Anaphylaxis Almost any food can cause anaphylactic reactionAlmost any food can cause anaphylactic reaction Some foods more common than others:Some foods more common than others:

PeanutPeanut Tree nutsTree nuts ShellfishShellfish FishFish EggEgg

In children under three yearsIn children under three years Cow’s milkCow’s milk EggEgg WheatWheat ChickenChicken

12

Exercise-induced AnaphylaxisExercise-induced Anaphylaxis Usually occurs within two hours of eating the Usually occurs within two hours of eating the

allergenic foodallergenic food Onset during physical activityOnset during physical activity Foods most frequently reported to have induced Foods most frequently reported to have induced

exercise-induced anaphylaxis:exercise-induced anaphylaxis: Wheat (omega-5-gliadin) and other grainsWheat (omega-5-gliadin) and other grains Celery and other vegetablesCelery and other vegetables Shellfish (shrimp; oysters)Shellfish (shrimp; oysters) ChickenChicken SquidSquid Peaches and other fruitsPeaches and other fruits Nuts especially hazelnutNuts especially hazelnut Peanuts and soy beansPeanuts and soy beans

May be associated with aspirin ingestionMay be associated with aspirin ingestion

13

Emergency Treatment forEmergency Treatment for Anaphylactic Reaction Anaphylactic Reaction

Injectable adrenalin (epinephrine)Injectable adrenalin (epinephrine) Fast-acting antihistamine (e.g. Benadryl)Fast-acting antihistamine (e.g. Benadryl) Usually in form of TwinJectUsually in form of TwinJect®® or Epipen or Epipen®® Transport to hospital immediatelyTransport to hospital immediately Second phase of reaction is sometimes fatal, Second phase of reaction is sometimes fatal,

especially in an asthmaticespecially in an asthmatic Patient may appear to be recovering, but 2-4 hours Patient may appear to be recovering, but 2-4 hours

later symptoms increase in severity and reaction later symptoms increase in severity and reaction progresses rapidly progresses rapidly

14

Immunologically Mediated Immunologically Mediated ReactionsReactions

IgE-mediated:IgE-mediated: Immediate onset (anaphylaxis)Immediate onset (anaphylaxis) Oral allergy syndrome (OAS)Oral allergy syndrome (OAS) Latex-Food syndromeLatex-Food syndrome

Non-IgE-mediatedNon-IgE-mediated Eosinophilic gastrointestinal diseasesEosinophilic gastrointestinal diseases Food protein-sensitive enteropathiesFood protein-sensitive enteropathies Gluten-sensitive enteropathy (celiac disease)Gluten-sensitive enteropathy (celiac disease)

15

Role of the DietitianRole of the Dietitian

Accurate identification of the foods Accurate identification of the foods responsibleresponsible Elimination and challenge to confirm or refute:Elimination and challenge to confirm or refute:

allergy testsallergy tests suspected allergens and intolerance triggerssuspected allergens and intolerance triggers

Directives for avoidance of the culprit foodsDirectives for avoidance of the culprit foods Recognition of sources of the offendersRecognition of sources of the offenders Understanding new labelling lawsUnderstanding new labelling laws

16

The Dietitian’s RoleThe Dietitian’s Role

Provide guidelines and resources to ensure complete Provide guidelines and resources to ensure complete balanced nutrition from alternative foodsbalanced nutrition from alternative foods MacronutrientsMacronutrients MicronutrientsMicronutrients

Directives for prevention of food allergy and Directives for prevention of food allergy and induction of oral toleranceinduction of oral tolerance New guidelinesNew guidelines

Ensure freedom from allergens in food provision and Ensure freedom from allergens in food provision and preparation services preparation services

Tests for Adverse ReactionsTests for Adverse Reactions to Foods to Foods

Rationale and LimitationsRationale and Limitations

18

Skin Tests:Skin Tests: Value in Practice Value in Practice

Positive predictive accuracy of skin tests Positive predictive accuracy of skin tests rarely exceeds 50%rarely exceeds 50% Many practitioners rate them lowerMany practitioners rate them lower

Negative skin tests do not rule out the Negative skin tests do not rule out the possibility of non-IgE-mediated reactionspossibility of non-IgE-mediated reactions

Do not rule out non-immune-mediated food Do not rule out non-immune-mediated food intolerancesintolerances

19

Value of SkinValue of Skin Tests in PracticeTests in Practice

Tests for highly allergenic foods thought to Tests for highly allergenic foods thought to have close to 100% have close to 100% negativenegative predictive predictive accuracy for diagnosis of IgE-mediated accuracy for diagnosis of IgE-mediated reactionsreactions

Such foods include:Such foods include: Egg Egg Milk Milk Fish Fish Wheat Wheat Tree nuts Tree nuts Peanut Peanut

20

Blood TestsBlood Tests

RAST: radioallergosorbent test (e.g. ImmunoCap-RAST; RAST: radioallergosorbent test (e.g. ImmunoCap-RAST; Phadebas-RAST)Phadebas-RAST)

FAST; Fluorescence allergosorbent testFAST; Fluorescence allergosorbent test ELISA: enzyme-linked immunosorbent assayELISA: enzyme-linked immunosorbent assay

Designed to detect and measure levels of allergen-specific Designed to detect and measure levels of allergen-specific antibodiesantibodies

Used for detection of levels of allergen-specific IgEUsed for detection of levels of allergen-specific IgE May measure total IgE - thought to be indicative of “atopic May measure total IgE - thought to be indicative of “atopic

potential”potential” Some practitioners measure IgGSome practitioners measure IgG (especially IgG4(especially IgG4) ) by ELISAby ELISA

21

Value of Blood Tests in PracticeValue of Blood Tests in Practice

Blood tests have about the same sensitivity as skin Blood tests have about the same sensitivity as skin tests for identification of IgE-mediated sensitisation tests for identification of IgE-mediated sensitisation to food allergensto food allergens

There is often poor correlation between high level of There is often poor correlation between high level of anti-food IgE and symptoms when the food is eatenanti-food IgE and symptoms when the food is eaten

Many people with clinical signs of food allergy show Many people with clinical signs of food allergy show no elevation in IgEno elevation in IgE

Reasons for failure of blood tests to indicate foods Reasons for failure of blood tests to indicate foods responsible for symptoms are the same as those for responsible for symptoms are the same as those for skin testsskin tests

22

Value of Blood Tests in PracticeValue of Blood Tests in Practice

Anti-food antibodies (especially IgG) are Anti-food antibodies (especially IgG) are frequently detectable in all humans, frequently detectable in all humans, usually without any evidence of adverse usually without any evidence of adverse effecteffect

IgG production is likely to be the first IgG production is likely to be the first stage of development of oral tolerance to a stage of development of oral tolerance to a foodfood

Studies suggest that IgG4 indicates Studies suggest that IgG4 indicates protection or recovery from IgE-mediated protection or recovery from IgE-mediated food allergyfood allergy

23

Tests for Intolerance of Food AdditivesTests for Intolerance of Food Additives

There are no reliable skin or blood tests to detect food There are no reliable skin or blood tests to detect food additive intoleranceadditive intolerance

Skin prick tests for Skin prick tests for sulphitessulphites are sometimes positive are sometimes positive

A negative skin test does not rule out sulphite sensitivityA negative skin test does not rule out sulphite sensitivity

History and oral challenge provocation of symptoms are History and oral challenge provocation of symptoms are the only methods for the diagnosis of additive the only methods for the diagnosis of additive sensitivity at presentsensitivity at present

CautionCaution: Challenge may occasionally induce : Challenge may occasionally induce anaphylaxis in sulphite-sensitive asthmaticsanaphylaxis in sulphite-sensitive asthmatics

24

Commercial Testing and Food Allergy Commercial Testing and Food Allergy Management ProgramsManagement Programs

LEAP (Lifestyle Eating and Performance); LEAP (Lifestyle Eating and Performance); Signet Diagnostic CorporationSignet Diagnostic Corporation Claims to “successfully treat … IBS, migraines, Claims to “successfully treat … IBS, migraines,

fibromyalgia, autism, ADD/ADHD, IBD, urticaria, fibromyalgia, autism, ADD/ADHD, IBD, urticaria, chronic fatigue syndrome, obesity, etc.”chronic fatigue syndrome, obesity, etc.”

Negative aspects:Negative aspects: Testing based on “mediator release”Testing based on “mediator release” Not a recognized accurate method for allergy testingNot a recognized accurate method for allergy testing

Positive aspectsPositive aspects Management includes elimination and challenge, food Management includes elimination and challenge, food

substitutions and meal planningsubstitutions and meal planning

25

Commercial Testing and Food Allergy Commercial Testing and Food Allergy Management ProgramsManagement Programs

Gemoscan Corporation:Gemoscan Corporation: HEMOCODE™ (Gemoscan) Food Intolerance System, HEMOCODE™ (Gemoscan) Food Intolerance System,

and MenuWise™ Food Intolerance Plan “personalized and MenuWise™ Food Intolerance Plan “personalized naturopathic nutritional programs that promote well-naturopathic nutritional programs that promote well-being.” being.”

Available in retail stores (Rexall and Loblaws) Price is $450 for 250 foods Tests identify IgG antibody to foods Customers receive support from pharmacist/naturopath,

including consultation on appropriate vitamins and supplements

Negative aspects There is no provision for dietetic counselling and thus a high

risk for nutritional deficiency when the “reactive foods” are eliminated without sufficient knowledge to provide nutrients from alternate sources

26

Unorthodox TestsUnorthodox Tests

Many people turn to unorthodox tests when avoidance Many people turn to unorthodox tests when avoidance of foods positive by conventional test methods have of foods positive by conventional test methods have been unsuccessful in managing their symptomsbeen unsuccessful in managing their symptoms

Tests include:Tests include: Vega test (electro-dermal)Vega test (electro-dermal) Biokinesiology (muscle strength)Biokinesiology (muscle strength) Analysis of hair, urine, salivaAnalysis of hair, urine, saliva RadionicsRadionics ALCAT (lymphocyte cytotoxicity)ALCAT (lymphocyte cytotoxicity)

27

Drawbacks of Unreliable TestsDrawbacks of Unreliable Tests

Diagnostic inaccuracyDiagnostic inaccuracy Therapeutic failureTherapeutic failure False diagnosis of allergyFalse diagnosis of allergy Creation of fictitious disease entitiesCreation of fictitious disease entities Failure to recognize and treat genuine diseaseFailure to recognize and treat genuine disease Inappropriate and unbalanced dietsInappropriate and unbalanced diets Risk of nutritional deficiencies and diet-Risk of nutritional deficiencies and diet-

related diseaserelated disease

Non-IgE-Mediated Non-IgE-Mediated AllergiesAllergies

Eosinophilic Gastrointestinal Diseases Eosinophilic Gastrointestinal Diseases Food Protein Induced Enteropathies Food Protein Induced Enteropathies

29

Eosinophilic Gastrointestinal Eosinophilic Gastrointestinal Diseases (EGID)Diseases (EGID)

Expanded definition of food allergy now Expanded definition of food allergy now encompasses any immunological response to food encompasses any immunological response to food components that results in symptoms when the food components that results in symptoms when the food is consumedis consumed

Example is group of conditions in the digestive tract Example is group of conditions in the digestive tract in which infiltration of eosinophils is diagnostic in which infiltration of eosinophils is diagnostic

Collectively these diseases are becoming known as Collectively these diseases are becoming known as eosinophilic gastrointestinal diseases (EGID).eosinophilic gastrointestinal diseases (EGID).

30

Characteristics of EGIDCharacteristics of EGID

Inflammatory mediators are released from Inflammatory mediators are released from the eosinophils, and act on local tissues in the eosinophils, and act on local tissues in the esophagus and gastrointestinal tract, the esophagus and gastrointestinal tract, causing inflammationcausing inflammation

In eosinophilic digestive diseases there is In eosinophilic digestive diseases there is no evidence of IgE, therefore tests for IgE-no evidence of IgE, therefore tests for IgE-mediated allergy are usually negativemediated allergy are usually negative

Unless there is a concomitant IgE-mediated Unless there is a concomitant IgE-mediated reaction to foodreaction to food

31

Eosinophilic EsophagitisEosinophilic Esophagitis Symptoms most frequently associated with EO Symptoms most frequently associated with EO

and considered to be typical of the disease include:and considered to be typical of the disease include: VomitingVomiting Regurgitation of foodRegurgitation of food Difficulty in swallowing: foods are said to be sticking Difficulty in swallowing: foods are said to be sticking

on the way downon the way down Choking on foodChoking on food Heartburn and chest painHeartburn and chest pain Water brash (regurgitation of a watery fluid not Water brash (regurgitation of a watery fluid not

containing food material)containing food material) Poor eatingPoor eating Failure to thrive (poor or no weight gain, or weight Failure to thrive (poor or no weight gain, or weight

loss)loss)

32

Eosinophilic EsophagitisEosinophilic Esophagitis Although the symptoms resemble gastro-Although the symptoms resemble gastro-

esophageal reflux disease (GERD), the esophageal reflux disease (GERD), the reflux of EO dose not respond to the reflux of EO dose not respond to the medications used to suppress the gastric medications used to suppress the gastric acid and control regurgitation (antireflux acid and control regurgitation (antireflux therapy) in GERDtherapy) in GERD

There is emerging data to suggest that use There is emerging data to suggest that use of acid-suppressing medications may of acid-suppressing medications may predispose patients to the development of predispose patients to the development of EoEEoE

33

Diagnosis of EoEDiagnosis of EoE

Three criteria must be met:Three criteria must be met: Clinical symptoms of esophageal Clinical symptoms of esophageal

dysfunctiondysfunction Oesophageal biopsy with an eosinophil Oesophageal biopsy with an eosinophil

count of at least 15 eosinophils per high-count of at least 15 eosinophils per high-power (x400 mag) microscopy fieldpower (x400 mag) microscopy field

Exclusion of other possible causes of the Exclusion of other possible causes of the condition condition

Dellon ES 2013

34

Eosinophilic EsophagitisEosinophilic Esophagitis

Foods most frequently implicatedFoods most frequently implicated

in Childrenin Children

Egg Egg Cow’s milkCow’s milk SoySoy WheatWheat CornCorn PeanutsPeanuts

Tree nutsTree nuts ShellfishShellfish FishFish BeefBeef RyeRye

35

Six-Food Elimination Diet and EoESix-Food Elimination Diet and EoEAdult study 2013Adult study 2013

Foods eliminated:Foods eliminated: Cereals Cereals

WheatWheat RiceRice CornCorn

Milk and milk productsMilk and milk products EggsEggs Fish and seafoodFish and seafood Legumes including peanutsLegumes including peanuts SoySoy

Lucendo et al 2013

36

Six-Food Elimination Diet and Six-Food Elimination Diet and EoEEoE

Indicators of positive outcome:Indicators of positive outcome: Biopsy eosinophil count (Biopsy eosinophil count (< 15/hpf)< 15/hpf) Negative gastro-oesophageal refluxNegative gastro-oesophageal reflux

Reduced eosinophil count: 73.1% of subjectsReduced eosinophil count: 73.1% of subjects Maintained remission for 3 yearsMaintained remission for 3 years Incidence of single triggering factors:Incidence of single triggering factors:

Cow’s milk 61.9%Cow’s milk 61.9% Wheat 28.6%Wheat 28.6% Eggs 26.2%Eggs 26.2% Legumes 23.8%Legumes 23.8%

No correlation with allergy testsNo correlation with allergy tests

37

Eosinophilic Gastroenteritis:Eosinophilic Gastroenteritis:

Diagnosis by biopsy:Diagnosis by biopsy:Abnormal number of eosinophils in the Abnormal number of eosinophils in the stomach and small intestinestomach and small intestine


EggEgg Cow’s milkCow’s milk SoySoy WheatWheat

PeanutsPeanuts Tree nutsTree nuts ShellfishShellfish FishFish

38

Eosinophilic ProctocolitisEosinophilic Proctocolitis

Diagnosis by biopsy:Diagnosis by biopsy:Abnormal number of Eosinophils confined to the Abnormal number of Eosinophils confined to the coloncolon


Cow’s milkCow’s milk Soy proteinsSoy proteins

Most frequently develops within the first 60 days of lifeMost frequently develops within the first 60 days of life

Is a non-IgE-mediated conditionIs a non-IgE-mediated condition

39

Food Protein EnteropathiesFood Protein Enteropathies Increasing recognition of a group of non-IgE-Increasing recognition of a group of non-IgE-

mediated food-related gastrointestinal problems mediated food-related gastrointestinal problems associated with delayed or chronic reactionsassociated with delayed or chronic reactions

Conditions include:Conditions include: Food protein induced enterocolitis syndrome Food protein induced enterocolitis syndrome

(FPIES)(FPIES) Food protein induced proctocolitis (FPIP)Food protein induced proctocolitis (FPIP)

These digestive disorders tend to:These digestive disorders tend to: Appear in the first months of lifeAppear in the first months of life Be generally self-limitingBe generally self-limiting Typically resolve at about two years of ageTypically resolve at about two years of age

40

FPIES SymptomsFPIES Symptoms

Symptoms in infants typically include:Symptoms in infants typically include: Profuse vomitingProfuse vomiting Diarrhoea, which can progress to dehydration and Diarrhoea, which can progress to dehydration and

shock in severe casesshock in severe cases Increased intestinal permeabilityIncreased intestinal permeability MalabsorptionMalabsorption DysmotilityDysmotility Abdominal painAbdominal pain Failure to thrive (typically weight gain less than 10 Failure to thrive (typically weight gain less than 10

g/day)g/day) In severe episodes the child may be hypothermic In severe episodes the child may be hypothermic

(<36 degrees C)(<36 degrees C)

41

FPIES CharacteristicsFPIES Characteristics Triggered by foods, but not mediated by IgETriggered by foods, but not mediated by IgE Condition typically develops in response to food Condition typically develops in response to food

proteins as a result of digestive tract and proteins as a result of digestive tract and immunological immaturityimmunological immaturity

Cow’s milk and soy proteins, usually given in Cow’s milk and soy proteins, usually given in infant formulae, reported as most frequent causes infant formulae, reported as most frequent causes

Milk and soy-associated FPIES usually starts Milk and soy-associated FPIES usually starts within the first year of life; most frequently within within the first year of life; most frequently within the first six or seven monthsthe first six or seven months

When solids foods are introduced, other foods When solids foods are introduced, other foods may cause the conditionmay cause the condition

Recent research claims that rice is the most Recent research claims that rice is the most common food causing FPIEScommon food causing FPIES

42

Foods Associated with FPIESFoods Associated with FPIES

Removal of the culprit foods usually leads to Removal of the culprit foods usually leads to immediate recovery from the symptomsimmediate recovery from the symptoms

Foods that have been identified as triggers of FPIES Foods that have been identified as triggers of FPIES in individual cases include:in individual cases include:

MilkMilk Cereals (oats, barley and rice)Cereals (oats, barley and rice) Legumes (peas, peanuts, soy, lentils)Legumes (peas, peanuts, soy, lentils) Vegetables (sweet potato, squash)Vegetables (sweet potato, squash) Poultry (chicken, turkey)Poultry (chicken, turkey) Egg Egg

43

Prevention of FPIESPrevention of FPIES Most reports of FPIES indicate that exclusive Most reports of FPIES indicate that exclusive

breast-feeding is protective in potential cases of breast-feeding is protective in potential cases of FPIESFPIES

None of the infants who later developed FPIES None of the infants who later developed FPIES after the introduction of solids had symptoms after the introduction of solids had symptoms while being exclusively breast-fedwhile being exclusively breast-fed

Authors of these studies suggest that babies with Authors of these studies suggest that babies with FPIES while being breast-fed were sensitized to FPIES while being breast-fed were sensitized to the proteins through an infant formula given the proteins through an infant formula given during a period of immunological susceptibilityduring a period of immunological susceptibility

44

Diagnosis and Management of FPIESDiagnosis and Management of FPIES

There are no diagnostic tests for FPIES at There are no diagnostic tests for FPIES at presentpresent

Indicators include clinical presentation :Indicators include clinical presentation : development of acute symptoms development of acute symptoms

immediately after consumption of the immediately after consumption of the offending foods (often milk- or soy-based offending foods (often milk- or soy-based infant formula)infant formula)

absence of positive tests for food allergy absence of positive tests for food allergy Elimination and challenge with the suspect Elimination and challenge with the suspect

foods will usually confirm the syndromefoods will usually confirm the syndrome

45

Diagnosis and Management of FPIESDiagnosis and Management of FPIES

Removal of the offending food leads to Removal of the offending food leads to symptom resolutionsymptom resolution

In most cases delayed introduction of solid In most cases delayed introduction of solid foods is advised because of the possibility that foods is advised because of the possibility that until the child’s immune system has matured, a until the child’s immune system has matured, a similar reaction to proteins in other foods may similar reaction to proteins in other foods may elicit the same responseelicit the same response

46

Food Protein Induced Food Protein Induced Proctitis/ProctocolitisProctitis/Proctocolitis

Blood in the stool is typicalBlood in the stool is typical Condition typically appears in the first few months Condition typically appears in the first few months

of life, on average at the age of two monthsof life, on average at the age of two months The The absenceabsence of other symptoms, such as vomiting, of other symptoms, such as vomiting,

diarrhoea, and lack of weight gain (failure to diarrhoea, and lack of weight gain (failure to thrive) usually rules out other causes such as food thrive) usually rules out other causes such as food allergy, and food protein enteropathiesallergy, and food protein enteropathies

Usually the blood loss is very slight, and anaemia Usually the blood loss is very slight, and anaemia as a consequence of loss of blood is rareas a consequence of loss of blood is rare

Diagnosis is usually made after other conditions Diagnosis is usually made after other conditions that could account for the blood, such as anal that could account for the blood, such as anal fissure and infection, have been ruled outfissure and infection, have been ruled out

47

Food Triggers of FPIPFood Triggers of FPIP

Most common triggers of FPIP include:Most common triggers of FPIP include: Cow’s milk proteinsCow’s milk proteins Soy proteinsSoy proteins Occasionally eggOccasionally egg

Many babies develop the symptoms during Many babies develop the symptoms during breast-feeding in response to milk and soy breast-feeding in response to milk and soy in the mother’s dietin the mother’s diet

48

Causes and Management of Causes and Management of FPIPFPIP

The cause of FPIP is unknown, but does not The cause of FPIP is unknown, but does not involve IgE, so all tests for allergy are usually involve IgE, so all tests for allergy are usually negativenegative

In most cases, avoidance of the offending food In most cases, avoidance of the offending food leads to a resolution of the problemleads to a resolution of the problem

When the baby is breast-fed, elimination of milk When the baby is breast-fed, elimination of milk and soy from the mother’s diet is usually enough and soy from the mother’s diet is usually enough to resolve the infant’s symptomsto resolve the infant’s symptoms

Occasionally egg can cause the symptoms, in Occasionally egg can cause the symptoms, in which case, mother must avoid all sources of egg which case, mother must avoid all sources of egg in her diet as well in her diet as well

49

Progression of FPIPProgression of FPIP

In most cases, the disorder will resolve by the In most cases, the disorder will resolve by the age of 1 or 2 yearsage of 1 or 2 years

After this age, the offending foods may be After this age, the offending foods may be reintroduced gradually, with careful reintroduced gradually, with careful monitoring for the reappearance of blood in monitoring for the reappearance of blood in the baby’s stoolthe baby’s stool

Elimination and Challenge Protocols

51

Identification of Allergenic FoodsIdentification of Allergenic Foods

Removal of the suspect foods from the diet, Removal of the suspect foods from the diet, followed by reintroduction is the only way followed by reintroduction is the only way to:to: Identify the culprit food componentsIdentify the culprit food components Confirm the accuracy of any allergy testsConfirm the accuracy of any allergy tests

Long-term adherence to a restricted diet Long-term adherence to a restricted diet should notshould not be advocated without clear be advocated without clear identification of the culprit food identification of the culprit food componentscomponents

52

Food Intolerance: Clinical DiagnosisFood Intolerance: Clinical Diagnosis

Symptoms Disappear

Elimination Diet: Avoid Suspect Food

Symptoms Persist

Increase Restrictions

Reintroduce Foods Sequentially or Double-blind

Symptoms Provoked No Symptoms

Diagnosis Confirmed Diagnosis Not Confirmed

53

Elimination and ChallengeElimination and Challenge

Stage 1Stage 1: : Exposure DiaryExposure Diary Record each day, for a minimum of 5-7 days:Record each day, for a minimum of 5-7 days:

All foods, beverages, medications, and supplements All foods, beverages, medications, and supplements ingestedingested

Composition of compound dishes and drinks, Composition of compound dishes and drinks, including additives in manufactured foodsincluding additives in manufactured foods

Approximate quantities of eachApproximate quantities of each The time of consumptionThe time of consumption

54

Exposure Diary (continued)Exposure Diary (continued)

All symptoms graded on severity:All symptoms graded on severity: 1 (mild); 1 (mild); 2 (mild-moderate) 2 (mild-moderate)

3 (moderate) 3 (moderate) 4 (severe) 4 (severe)

Time of onsetTime of onset

How long they lastHow long they last

Record status on waking in the morning.Record status on waking in the morning. Was sleep disturbed during the night, and if so, Was sleep disturbed during the night, and if so,

was it due to specific symptoms?was it due to specific symptoms?

55

Elimination DietElimination Diet

Based onBased on:: Detailed medical historyDetailed medical history Analysis of Analysis of Exposure DiaryExposure Diary Any previous allergy testsAny previous allergy tests Foods suspected by the patientFoods suspected by the patient

Formulate dietFormulate diet to exclude all suspect allergens to exclude all suspect allergens and intolerance triggersand intolerance triggers

ProvideProvide excluded nutrients from alternative excluded nutrients from alternative sourcessources

DurationDuration: Usually four weeks: Usually four weeks

56

Selective Elimination DietsSelective Elimination Diets

Certain conditions tend to be associated with specific food componentsCertain conditions tend to be associated with specific food components Suspect food components are those that are probable triggers or mediators Suspect food components are those that are probable triggers or mediators

of symptomsof symptoms ExamplesExamples::

Eczema: Eczema: Highly allergenic foodsHighly allergenic foods Migraine: Migraine: Biogenic aminesBiogenic amines Urticaria/angioedema: Urticaria/angioedema: HistamineHistamine Chronic diarrhea:Chronic diarrhea: Carbohydrates; DisaccharidesCarbohydrates; Disaccharides Asthma: Asthma: Cyclo-oxygenase inhibitors Cyclo-oxygenase inhibitors

SulphitesSulphites Latex allergy:Latex allergy: Foods with structurally Foods with structurally

similar antigens to latexsimilar antigens to latex Oral allergy syndrome: Oral allergy syndrome: Foods with structurally Foods with structurally

similar antigens to pollenssimilar antigens to pollens

57

Few Foods Elimination DietFew Foods Elimination Diet

When it is difficult to determine which foods When it is difficult to determine which foods are suspects a few foods elimination diet is are suspects a few foods elimination diet is followedfollowed Limited to a very small number of foods and Limited to a very small number of foods and

beveragesbeverages Limited time: 10-14 days for an adultLimited time: 10-14 days for an adult 7 days maximum for a child7 days maximum for a child

If all else fails use elemental formulae:If all else fails use elemental formulae: May use extensively hydrolysed formula for a May use extensively hydrolysed formula for a

young childyoung child

58

Expected Results of Elimination DietExpected Results of Elimination Diet

Symptoms often worsen on days 2-4 of Symptoms often worsen on days 2-4 of eliminationelimination

By day 5-7 symptomatic improvement is By day 5-7 symptomatic improvement is experiencedexperienced

Symptoms disappear after 10-14 days of Symptoms disappear after 10-14 days of exclusionexclusion

59

ChallengeChallenge

Double-blind Placebo-controlled Food Challenge Double-blind Placebo-controlled Food Challenge (DBPCFC)(DBPCFC) Lyophilized (freeze-dried) food is disguised in Lyophilized (freeze-dried) food is disguised in

gelatin capsulesgelatin capsules Identical gelatin capsules contain a placebo Identical gelatin capsules contain a placebo

(glucose powder)(glucose powder) Neither the patient nor the supervisor knows the Neither the patient nor the supervisor knows the

identity of the contents of the capsulesidentity of the contents of the capsules Positive test is when the food triggers symptoms Positive test is when the food triggers symptoms

and the placebo does notand the placebo does not

60

ChallengeChallenge (continued) (continued)

Drawback of DBPCFCDrawback of DBPCFC Expensive in time and personnelExpensive in time and personnel Capsule may not provide enough food to Capsule may not provide enough food to

elicit a positive reactionelicit a positive reaction Patient may be allergic to gelatin in Patient may be allergic to gelatin in

capsulecapsule May be other factors involved in eliciting May be other factors involved in eliciting

symptoms, e.g. taste and smellsymptoms, e.g. taste and smell

61

Challenge Challenge (continued)(continued)

Single-blind food challenge (SBFC)Single-blind food challenge (SBFC)Supervisor knows the identity of the Supervisor knows the identity of the

food; patient does notfood; patient does notFood is disguised in a strong-tasting Food is disguised in a strong-tasting

“inert” food tolerated by the patient:“inert” food tolerated by the patient: lentil souplentil soup apple sauceapple sauce tomato sauce tomato sauce

62

Challenge Phase Challenge Phase continuedcontinued

Open food challengeOpen food challenge Sequential Incremental Dose Challenge (SIDC)Sequential Incremental Dose Challenge (SIDC) Each food component is introduced separatelyEach food component is introduced separately Starting with a small quantity and increasing the Starting with a small quantity and increasing the

amount according to a specific scheduleamount according to a specific schedule This is usually employed when the symptoms are This is usually employed when the symptoms are

mild, and the patient has eaten the food in the mild, and the patient has eaten the food in the past without a severe reactionpast without a severe reaction

Any food suspected to cause a severe or anaphylactic Any food suspected to cause a severe or anaphylactic reaction should only be challenged in suitably reaction should only be challenged in suitably equipped medical facilityequipped medical facility

63

Open Food ChallengeOpen Food Challenge

Each food or food component is introduced Each food or food component is introduced individuallyindividually

The basic elimination diet, or therapeutic diet The basic elimination diet, or therapeutic diet continues during this phasecontinues during this phase

If an adverse reaction to the test food occurs at If an adverse reaction to the test food occurs at any time during the test STOP. any time during the test STOP.

Wait 48 hours after all symptoms have Wait 48 hours after all symptoms have subsided before testing another foodsubsided before testing another food

64

Incremental Dose ChallengeIncremental Dose Challenge

Day 1: Day 1: Consume test food between mealsConsume test food between meals

MorningMorning: Eat a small quantity of the test food: Eat a small quantity of the test food

Wait four hours, monitoring for adverse reactionWait four hours, monitoring for adverse reaction

If no symptoms:If no symptoms: AfternoonAfternoon: Eat double the quantity of test food eaten in : Eat double the quantity of test food eaten in

the morningthe morning

Wait four hours, monitoring for adverse reaction Wait four hours, monitoring for adverse reaction

If no symptoms:If no symptoms: EveningEvening: Eat double the quantity of test food eaten in : Eat double the quantity of test food eaten in

the afternoonthe afternoon

65

Incremental Dose ChallengeIncremental Dose Challenge (continued) (continued)

Day 2:Day 2:

Do not eat any of the test foodDo not eat any of the test food Continue to eat basic elimination dietContinue to eat basic elimination diet Monitor for any adverse reactions during the Monitor for any adverse reactions during the

night and day which may be due to a delayed night and day which may be due to a delayed reaction to the test foodreaction to the test food

66

Day 3:Day 3: If no adverse reactions experiencedIf no adverse reactions experienced

Proceed to testing a new food, starting Day 1Proceed to testing a new food, starting Day 1

If the results of Day 1 and/or Day 2 are unclear :If the results of Day 1 and/or Day 2 are unclear : Repeat Day 1, using the same food, the same test Repeat Day 1, using the same food, the same test

protocol, but larger doses of the test food protocol, but larger doses of the test food

Day 4:Day 4: Monitor for delayed reactions as on Day 2Monitor for delayed reactions as on Day 2

Incremental Dose Challenge(continued)

67

Sequential Incremental Dose ChallengeSequential Incremental Dose Challenge

Continue testing in the same manner until all Continue testing in the same manner until all excluded foods, beverages, and additives have excluded foods, beverages, and additives have been testedbeen tested

For each food component, the first day is the For each food component, the first day is the test day, and the second is a monitoring day test day, and the second is a monitoring day for delayed reactionsfor delayed reactions

Maintenance DietMaintenance Diet

69

Final DietFinal Diet

Must exclude all foods and additives to which a Must exclude all foods and additives to which a positive reaction has been recordedpositive reaction has been recorded

Must be nutritionally complete, providing all Must be nutritionally complete, providing all macro and micro-nutrients from non-allergenic macro and micro-nutrients from non-allergenic sourcessources

There is no benefit from a rotation diet in There is no benefit from a rotation diet in the management of the management of food allergyfood allergy

A rotation diet may be beneficial when the A rotation diet may be beneficial when the condition is due to dose-dependent condition is due to dose-dependent food food intoleranceintolerance

70

Minerals Milk Egg Peanut TreeNuts

Seeds Soy Fish Shellfish

Wheat Corn

Calcium + + + + +

Phosphorus + + + + + + + +

Iron + + + + + + + +

Zinc + + + + + + +

Magnesium + + + + + +

Selenium + + + + + + +

Potassium + + + + +

Molybdenum +

Chromium + + +

Copper + + + + +

Manganese + + +

IMPORTANT NUTRIENTS IN COMMON ALLERGENS

71

Vitamins Milk Egg Peanut Nuts Seeds Soy Fish Shellfish Wheat Corn

A + + + + +

Biotin + + +

Folate + + + + + +

Thiamin + + + + + +

Riboflavin + + + + + + +

Niacin + + + + + + +

Pantothenic acid

+ + + + +

B6 (Pyridoxine) + + + + + + +

B12 + + + +

D ++ ++ ++ ++

E + + ++ ++ ++ +

K + + ++

72

SummarySummaryFood AllergyFood Allergy::

Immune system responseImmune system response

Food Intolerance:Food Intolerance: Usually metabolic dysfunctionUsually metabolic dysfunction

Diagnostic Laboratory TestsDiagnostic Laboratory Tests:: Often ambiguous because different physiological Often ambiguous because different physiological

mechanisms are involved in triggering symptomsmechanisms are involved in triggering symptoms

73

SummarySummary

Reliable testsReliable tests for the detection of for the detection of adverse reactions to foods:adverse reactions to foods:

Elimination and ChallengeElimination and Challenge

Final dietFinal diet

Must provide complete nutrition while Must provide complete nutrition while avoiding all of the foods and food avoiding all of the foods and food components that elicit symptoms on components that elicit symptoms on challengechallenge

Health & Medicine

Dr.Janice Joneja. Success with Food Allergy and Intolerance