eMedicine Specialties > Allergy and Immunology > Major Allergic Diseases

Food Allergies: Follow-up

Author: Scott H Sicherer, MD, Associate Professor of Pediatrics, Mount Sinai School of Medicine of New York University
Contributor Information and Disclosures

Updated: Sep 2, 2009

Follow-up

Deterrence/Prevention

  • Emergency plan
    • Provide a written emergency treatment plan for the patient. Have copies of this plan available in appropriate places (eg, daycare, schools, work locations, college dormitory advisors).
    • Patients with food allergies should be advised to obtain and wear medical identification jewelry indicating their food allergies.
    • Ensure that the patient has an emergency contact number available (eg, 911, their physician's office phone number, or a local emergency department) that can be used in the event of a major food-induced allergic reaction.
    • Anticipatory guidance measures cannot be overemphasized; for example, educate the patient about potential sources of accidental or inadvertent exposure to relevant food allergens (eg, daycare, school, travel, picnics, dining out).
  • Emergency medications
    • Ensure that the patient has self-injectable epinephrine readily available at all times. Also ensure that the patient receives proper training regarding when and how to use the device. An antihistamine should also be available. Patients with food allergies and asthma should always have access to a rapid-acting bronchodilator.
    • Self-injectable epinephrine is typically available by prescription (ie, EpiPen, EpiPen Jr, Twinject 0.3 mg, Twinject 0.15 mg). These devices should be stored properly (avoiding extremes of temperature) and replaced before the expiration date.
    • Injectable epinephrine is the drug of choice for the initial management of a food-induced anaphylactic reaction.

Prognosis

  • Developing tolerance
    • In general, most infants and young children outgrow or become clinically tolerant of their food hypersensitivities. Specifically, most "outgrow" allergies to milk, egg, soy and wheat. Allergies to peanut, tree nuts, fish, and shellfish are more persistent.60
    • Population-based studies generally show that 85% of young children outgrow their allergy to milk or egg by age 3-5 years.60 However, recent studies reported from a referral center showed more persistence of egg and milk allergies, with only about 50% of patients resolving these allergies by age 8-12 years.61,62 Children continued to lose their allergy into adolescent years.
    • About 20% of infants and young children experience resolution of their peanut allergy by the time they reach school age.63
    • Children with non-IgE – mediated food allergies such as proctocolitis and enterocolitis typically resolve their food allergy in the first years of life.64
    • Allergic eosinophilic esophagitis appears to be a persistent disorder.65
  • Avoidance of allergen: Strict avoidance of allergen is generally required to prevent allergic reactions. Whether strict avoidance or accidental exposures alters the natural course of food allergy remains unclear.66,67
  • Prevention of atopic disease through diet68
    • Numerous studies have evaluated the role of maternal/infant diet on outcomes of atopic disease (asthma, atopic dermatitis, food allergy), particularly through studies of infants at risk based upon family history of atopy (at least 1 first-degree relative with a documented atopic disease). Most studies have focused upon elimination of allergens or a delay in introducing them. However, limitations in study design and number of studies have limited the ability to draw firm conclusions on a number of potential interventions.
    • Evidence for a protective effect of maternal allergen avoidance during pregnancy or lactation is lacking; however, some evidence supports a reduction in atopic dermatitis when allergens are avoided during lactation.
    • For infants at risk, some evidence shows that exclusive breastfeeding for at least 3 months protects against wheezing in early life.
    • In studies of infants at risk who are not exclusively breastfed for 4-6 months, modest evidence shows that using specific extensively hydrolyzed casein-based or partially hydrolyzed whey-based formulas reduces the risk of (or delays) atopic dermatitis when compared to feeding with a whole cow milk protein – based formula. Soy formula does not appear to offer an advantage compared to whole cow milk – based infant formula.
    • No current convincing evidence supports the delay of specific allergenic foods beyond 4-6 months of life.
    • Once allergic disease is noted, allergen elimination may be needed for treatment.
    • Further studies are needed to clarify the role of early elimination diets and breastfeeding in the prevention of food allergy.

Patient Education

  • Preparation
    • Patients should always carry an epinephrine self-injectable device that has been properly stored and is current (ie, not expired).
    • Patients should also have an H1-blocker medication (again, properly stored and not expired) in a syrup or chewable tablet form available.
  • Avoidance of allergen
    • Complete avoidance of the offending food allergen is the best strategic approach and the only proven therapy once the diagnosis of food hypersensitivity is established; therefore, these patients should be properly taught to recognize relevant food allergens that must be eliminated from their diet.
    • Instruct the patient about the proper reading of food labels and the need to inquire about food ingredients when dining out.
    • If the patient is in doubt about a food or food ingredient, suggest avoidance of the food in question.
  • Support groups
    • Inform patients with food allergies how to identify and use support groups.
    • One such organization is the Food Allergy and Anaphylaxis Network (10400 Eaton Place, Suite 107, Fairfax, VA, 22030-2208 USA; fax: 703-691-2713; phone: 703-691-3179 or 800-929-4040; email: faan@foodallergy.org). 
  • Early detection
    • Educate patients regarding recognition of the early signs and symptoms of a food-induced allergic reaction, and provide them with a written management plan for successfully dealing with these reactions.
    • Write a specific list of clinical signs and symptoms to look for if a reaction may be occurring, and include a clear management plan. An excellent example of such a plan is available on the Food Allergy and Anaphylaxis Network Web site.
    • Demonstrate to the patient and family how to actually administer medications, especially injectable epinephrine, in the event of an allergic reaction. To accomplish this, use demonstration trainer devices in the clinic setting. Reinforce that if injectable epinephrine is administered, the patient must be immediately evaluated in a medical setting.
  • For excellent patient education resources, visit eMedicine's Allergy Center and Allergic Reaction and Anaphylactic Shock Center. Also, see eMedicine's patient education articles Food Allergy and Severe Allergic Reaction (Anaphylactic Shock).

Miscellaneous

Medicolegal Pitfalls

  • When performing oral food challenges, be prepared to recognize and treat adverse clinical symptoms immediately. Appropriately trained personnel and the necessary equipment for the treatment of anaphylactic shock must be available prior to and throughout the entire oral food challenge and observation period because of the risk of triggering an allergic reaction.
  • Patients should never be instructed to perform a food challenge at home.
  • Confirm negative results from a double-blind, placebo-controlled food challenge (DBPCFC) using an open feeding (open food challenge) of the food in question in its usual form and quantity before giving final advice on dietary restrictions.
  • If the patient has a history of severe allergic reactions following the ingestion of food allergens, give specific advice in the form of a written emergency treatment plan. In addition, educate the patient on how to administer emergency medications (eg, injectable epinephrine, antihistamines) in the event of a severe life-threatening allergic reaction. Encourage patients (when appropriate) or caretakers to carry these medications at all times in case they are needed to manage symptoms.

Special Concerns

  • Future therapeutics69
    • No curative therapies currently for food allergy.
    • Injection immunotherapy is an accepted treatment for anaphylactic allergy to insect venoms and for environmental allergies, but poses a high risk for food allergies (anaphylaxis to injected native food proteins).
    • Studies are underway to determine if oral or sublingual immunotherapy is safe and effective for food allergy.
    • Studies are underway to determine whether therapies with modified food proteins are safe and effective.
    • Additional future therapeutics include investigations of anti-IgE antibodies, cytokine or anti-cytokine therapies, and evaluation of traditional Chinese medicine.
  • Diagnosis2
    • The clinician must appreciate that a positive test for food-specific IgE primarily denotes sensitization; additional consideration of the history, the epidemiology of food allergic disease, crossreactivity, and the degree of positivity of tests must be evaluated to assist in diagnosis. A physician-supervised oral food challenge may be required for diagnosis.
    • Because specific laboratory tests for some food hypersensitivities are not available, diagnosing non–IgE-mediated food allergies (eg, cow milk–induced and soy-induced enterocolitis syndromes, allergic eosinophilic gastroenteritis) is more difficult than diagnosing IgE-mediated food allergies.
    • In cases of allergic eosinophilic gastroenteritis, a biopsy may need to be performed. Elimination diets with gradual reintroduction of foods and supervised oral food challenges are often needed to help identify the causative foods.
    • For food protein–induced enterocolitis syndrome, perform a food challenge with 0.15-0.30 grams of protein per kilogram of body weight of the implicated protein and observe the patient for several hours. Positive reactions (eg, profuse vomiting and diarrhea) are typically accompanied by a rise in the absolute neutrophil count of more than 3500 cells/mm3. Because of the potential for shock, these challenges are best performed in the hospital setting.
    • When the history of an allergic reaction to a food suggests that the onset of symptoms is delayed by hours or days following ingestion, adjust the timing and monitoring of the challenge to correspond to these characteristics.
    • The successful administration of oral food challenges to young children requires a great deal of preparation, patience, and creativity. Young children may refuse to ingest the challenged food. Prior planning with the family is important to choose proper vehicles (eg, juice, cereal, solid food) for disguising the challenged substance.
  • Vaccines
    • Scientific data support the routine 1-dose administration of the measles-mumps-rubella vaccine to all patients with egg allergy, even those with severe anaphylactic reactions following egg ingestion.70 In the child with a history of a previous reaction to the measles-mumps-rubella vaccine, consider the possibility of allergy to gelatin, neomycin, or another component of the vaccine.
    • If the patient has a clinical history of egg allergy and has experienced systemic reactions (eg, anaphylaxis) following the ingestion of egg, the administration of the influenza vaccine requires special diagnostic consideration.71 After reviewing risks and benefits, the patient's skin can be tested with diluted preparations of the influenza vaccine (ie, puncture skin testing and, if needed, intradermal skin testing). If skin test results with the vaccine are positive, the vaccine can be given in a graded, multidose scheme. If results are negative, the vaccine may be administered in the routine 1-dose manner.
 
Acknowledgments

The author and editors of eMedicine gratefully acknowledge the contributions of previous authors Dan Atkins, MD, and John M James, MD, to the development and writing of this article.



More on Food Allergies

Overview: Food Allergies
Differential Diagnoses & Workup: Food Allergies
Treatment & Medication: Food Allergies
Follow-up: Food Allergies
References
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Further Reading

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Keywords

food allergies, food allergy, adverse immunologic reactions to foods, allergic reactions to foods, food hypersensitivity, food intolerance, food allergy test, food allergy symptoms, food allergy rash, food allergy treatment, allergy foods, adverse food reactions, lactose intolerance, bacterial food poisoning, peanut allergy, protein-induced enterocolitis syndrome, proctocolitis, food hypersensitivity, allergen exposure, anaphylactic reactions, food-induced anaphylactic reaction, oral allergy syndrome, dietary protein enterocolitis, food-induced asthma, food-induced pulmonary hemosiderosis, Heiner syndrome, egg allergy, milk allergy, peanut allergy, soy allergy, fish allergy, shellfish allergy, tree nut allergy, wheat allergy, celiac disease, childhood food allergy, lactose intolerant

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Contributor Information and Disclosures

Author

Scott H Sicherer, MD, Associate Professor of Pediatrics, Mount Sinai School of Medicine of New York University
Scott H Sicherer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
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CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
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