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BASIC INFORMATION

DEFINITION
Food allergies are divided into IgE-mediated and
immunologically mediated non-IgE reactions. They
include a spectrum of disorders that involve adverse
immunologic responses to a dietary antigens.

T78.1Other adverse food reactions, not

elsewhere classified
L27.2Dermatitis due to ingested food

EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE: Food allergies have a cumulative
incidence of 6% to 8% for the first 3 yr of life.
PREVALENCE:
Overall prevalence is 1% to 2% in general
population, ~3.9% -8% in children.
Patient self-reported food allergies have a
prevalence of 12% to 13%, demonstrating
the importance of objective measures in
assessing food allergies.


Nearly 40% of children with food allergy
have a history of severe reactions that, if not
treated immediately with proper medication,
can lead to hospitalization or even death.1
There is no predilection for race.
PREDOMINANT SEX: Males are more affected
than females among children, and among
adults, females are more frequently affected.
GENETICS: Children with parents or close
relatives with allergies may have a tendency to
become allergic to foods.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
IgE-mediated reactions: (within minutes to a
few hours) pruritus, urticaria or angioedema,
atopic dermatitis, GI symptoms, conjunctival
injection, sneezing, nasal congestion,
rhinorrhea, bronchospasm, and anaphylaxis


NonIgE-mediated reactions: food-induced
enterocolitis, celiac disease, Crohns disease,
dermatitis herpetiformis, and pulmonary
reactions such as Heiner syndrome. These
illnesses are discussed separately.


Signs, symptoms, and presentation reflect
specific allergic manifestation, but in food
allergies there is a reproducible temporal
relationship to ingested food allergens.
1Gupta RS et al: The prevalence, severity, and
distribution of childhood food allergy in the United
States, Pediatrics 128(I):e9-e17, 2011.

Dx DIAGNOSIS
Thorough history and physical exam should
be performed.
The temporal relationship and reproducibility
of the symptoms are most important to
establishing the diagnosis.
A review of ingredient labels may be helpful.
Confirmatory testing can include skin testing
or invitro testing.
Skin prick testing (SPT): positive predictive
value <50%, but negative predictive value
>95%. Thus a negative skin test effectively
rules out an IgE-mediated process.
Invitro testing: RAST testing: Historically it is
less sensitive than skin testing, but sensitivity
has improved with cut off points indicating a
positive predictive value of 95% for allergies
to eggs, milk, peanuts, wheat, and fish.
Neither the size of the wheal in skin prick
testing nor the IgE antibody level correlates
with severity. However, there may be some
increased positive predictive value with
larger wheals and higher titers.
Atopy patch test: used in conjunction with
RAST and skin testing in multiallergic
children to plan widening the elimination
diet. However, it is not recommended in the
routine evaluation of food allergies.


Double-blind, placebo-controlled food
challenges are the gold standard test for
determining food allergies. These need to be
done in a supervised and controlled setting.
In summary, if the history and lab tests are
suggestive of a specific food allergy, that food
should be confirmed by SPT, RAST, or food
challenge and, once confirmed, eliminated
from the diet.

DIFFERENTIAL DIAGNOSIS
Gastrointestinal disorders
Irritable bowel syndrome
Carcinoid syndrome
Giardiasis


Structural abnormalities like hiatal hernia,
pyloric stenosis, Hirschsprungs disease,
tracheoesophageal fistula

Disaccharidase deficiencies: lactase, sucraseisomaltase complex, glucose-galactosecomplex
Pancreatic insufficiency: cystic fibrosis
Gallbladder disease
Peptic ulcer disease
Malignancy
Metabolic disorders
Galactosemia
Phenylketonuria
Pharmacologic-related conditions
Gustatory rhinitis
Auriculotemporal syndrome (facial flush from
tart food)

Food Allergies

Rx TREATMENT
NONPHARMACOLOGIC THERAPY
Elimination diet should be used in conjunction with nutritional counseling.
Formula-fed infants: brief trial of hydrolyzed
milk formula as most children with milk
allergy induced skin symptoms will respond
to the change of formula. Nonresponders
may require amino acidbased formula.
In older children: elimination of one to two
suspected foods is appropriate for 2 wk or
longer and then reintroducing the foods to
determine if symptoms recur.
ACUTE GENERAL Rx
Antihistamines (both H1 and H2 antihistamines),
albuterol if wheezing, epinephrine and
glucocorticoids in patients with anaphylaxis.


Patients with documented IgE-mediated
reactions should receive and be counseled
on the use of epinephrine autoinjector.
NEW TREATMENTS FOR FOOD
ALLERGIES
Oral and sublingual immunotherapy may play
a role in management of food allergies, but
this is currently under investigation.


Recombinant
vaccines
and
other
immunomodulatory strategies are under
development, although monoclonal anti-IgE
antibody has shown benefit in adults with
peanut allergy.

PEARLS &
CONSIDERATIONS

Eczema that develops in first 6 to 12 mo of

life is usually the first manifestation of atopy.
Egg allergy or sensitization is the strongest
recognized predictor of respiratory allergies
in children and asthma in adults.
Consultation with trained dietitian is critical
to avoid potentially adverse nutritional
consequences in children with multiple food
allergies.


Skin testing is the preferred method for
identifying food-specific IgE. RAST is useful
if there is chance of severe food reaction
causing risk to the patient.


American Academy
of
Pediatrics
recommends avoiding influenza vaccine
in patients with severe systemic allergic
reactions to egg. Skin prick testing using
influenza vaccine containing egg is
recommended before vaccination in children
with egg allergy and asthma. Skin prick
testing not required before MMR vaccine in
children with egg allergy.

COMMENTS
Milk allergy usually resolves by age 5. Risk
factors for persistence are early cutaneous
manifestations following milk ingestion,
development of other atopic conditions, and
persistence of milk-specific high IgE titers.

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Diseases
and Disorders

ICD-9CM CODES
447.1Allergic rhinitis due to food
558.3Allergic gastroenteritis and colitis
693.1Dermatitis due to food taken internally
995.60Anaphylactic reaction due to
unspecified food
995.7Other adverse food reactions, not
elsewhere classified
ICD-10CM CODES
T78.0Adverse food reaction (including
anaphylactic shock)

ETIOLOGY
Failure to establish tolerance to food antigens.
Food proteins not broken down by proteolysis
are taken up by intestinal epithelial cells and
presented to primed T cells.

PTG

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Food Allergies

PTG

Soy milk is recommended for these children,

keeping in mind that about 15% of these
children can develop soy allergy.
Egg allergy has been thought to resolve in
66% of children by 5 yr of age and in 75%
of children by 7 yr of age. Trials have shown
that oral immunotherapy can desensitize a
high proportion of children with egg allergy
and induce sustained unresponsiveness in a
clinically significant subset.
Wheat allergy found to resolve by 5 yr of age
and soybean allergy by 2 yr of age.

exclusive breastfeeding for 4 to 6 mo in

terms of developing food allergies.
In high-risk infants who are not exclusively
breast fed, there is limited evidence to
suggest that feeding with hydrolyzed formula
compared to cows milk formula reduces
allergies.
Currently, there is no evidence to support the
use of prebiotics, probiotics, or synbiotics for
the prevention of allergic diseases.
No current evidence exists to support delaying
the introduction of solid foods beyond 4 to 6 mo.

PREVENTION
There is conflicting evidence regarding the
protective effect of breastfeeding on food
allergies.
There is no evidence to suggest that exclusive
breastfeeding for 6 mo or more is superior to

PATIENT/FAMILY EDUCATION
Information can be found on American Academy of
Allergy, Asthma and Immunology (www.aaaai.org),
the Food Allergy and Anaphylaxis Network
(www.foodallergy.org), and the Anaphylaxis
Campaign (www.anaphylaxis.org.uk).

REFERRAL
Patients may be referred to an allergy/
immunology specialist when the diagnosis is
uncertain or if avoidance measures are not
successful.
SUGGESTED READINGS
available at www.expertconsult.com
RELATED CONTENT
Food Allergies (Patient Information)
AUTHOR: LUKE BARR, M.D.

Food Allergies
SUGGESTED READINGS
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Bock SA, Sampson HA: Double blind placebo controlled food challenge as an
office procedure: a manual, J Allergy Clin Immunol 82(6):986-997, 1988.
Boyce JA etal: Guidelines for the diagnosis and management of food allergy in
the United States: report of the NIAID-Sponsored Expert Panel, J Allergy Clin
Immunol 126(suppl):S1-S58, 2010.
Burks AW etal: Oral immunotherapy for treatment of egg allergy in children, N
Engl J Med 367:233-243, 2012.
Bush RH: Approach to patients with symptoms of food allergy, Am J Med 121:376-378,
2008.
Grimshaw KE etal: Infant feeding and allergy prevention: a review of current
knowledge and recommendations. A EuroPrevall state of the art paper, Allergy
64(10):1407-1416, 2009.
Gupta RS etal: Childhood food allergies: current diagnosis, treatment, and management strategies, Mayo Clin Proc 88(5):512-526, 2013.
Kagan RS: Food allergy: an overview, Environ Health Perspect 111(2):223-225,
2003.
Lack G: Clinical practice: food allergy, N Engl J Med 359(12):1252-1260, 2008.
Muraro A etal: The management of anaphylaxis in childhood: position paper
of the European Academy of Allergology and Clinical Immunology, Allergy
62(8):857-871, 2007.
NIAID-Sponsored Expert Panel: Guidelines for the diagnosis and management of
food allergy in the United States: Report of the NIAID-Sponsored Expert Panel,
J Allergy Clin Immunol 126(6):S1-S68, 2010.
Sampson HA: Atopic dermatitis, Ann Allergy 69:469-479, 1992.

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