Diagnosis and Management

of Food Allergy
Sumadiono

UKK ALERGI IMUNOLOGI IDAI

Learning Objective
Review definition , classification of food
hypersensitivity and food allergens in children

Differentiate between IgE-mediated, cellmediated and mixed IgE- and cell-mediated

food-related diseases in different organ
systems
Discuss the diagnosis of food allergy and
the limitations of diagnostic techniques
Review the

treatment

of food allergy
2

Definition
Adverse reaction to food:
Any abnormal clinical response attributed to ingestion,
contact or inhalation of any food, a food derivative or a
food additive

Food intolerance:
an adverse

physiologic

response

to a food and may be due to inherent

properties of the food or to characteristics of the host
May not be reproducible, and are often dose dependent

Food allergy:
an abnormal immunologic response to a food
that occurs in a susceptible host. These reactions are
reproducible each time the food is ingested and are often
not dose dependent.
3

Classification

Allergology International 2009; 58: 457-466

Main dominant food allergens

in some countries
USA & UK
Milk

ITALY

Egg

Milk

Peanut

Egg

Tree Nuts
Seafood

Seafood

SINGAPORE
Birds Nest
Seafood
Egg
Milk
AUSTRALIA
Milk
Egg

FRANCE
Egg
Peanuts
Milk
Mustard

ISRAEL
Milk

Peanuts
Sesame

Egg
Sesame
5

 The most common Food Allergen in

preschool and elementary school children
are:
Milk, egg whites, egg yolks,
seafood and tomatoes

Characteristic of Food Allergen

Sensitization
in YOGYAKARTA
No
Allergens
Yes (%)
1. milk
15 (3.3)
2. egg whites
14 (3.1)
3. egg yolks
11 (2.4)
4. fish 8 (1.8)
5. shrimp 53 (11.8)
6. peanuts
7 (1.6)
7 . crab
49 (10.9)
8. beef 9 7 (1.6)
9. chicken 10 7 (1.6)
8

Characteristic of Food Allergen

Sensitization
No
10.
11 .
12 .
13.
14.
15.
16.
17.
18.

Allergens
rice
corn
soy
wheat
apple
tomatoes
guava
oranges
bananas

Yes (%)
1 (0.2)
1 (0.2)
10 (2.2)
5 (1.1)
7 (1.6)
17 (3.8)
5 (1.1)
8 (1.8)
8 (1.8)
9

Pathogenesis based-disease
manifestation
IgE

IgE/Non-IgE

Non-IgE
Urticaria/angioedemAtopic
a
dermatitis
Rhinitis /Asthma
Anaphylaxis

Protein-induced
proctocolitis/
enterocolitis

Oral allergic
syndrome
Gastrointestinal
symptoms (GIT)

Celiac disease
Contact dermatitis
Herpetiform dermatitis
Heiners syndrome

Eosinophilic
gastro-intestinal
disorders

10

Diagnosing Food Allergy

Allergy History
Clinical Signs and Symptoms
Skin Test
(skin prick test, atopy patch
test)
Serum specific IgE test (RAST)
Elimination & Provocation test
11

Medical history
- Symptoms described by patient
- Length of time between ingestion and
development of symptoms: immediate:
minute to 2 hours suggestive for Ig E
mediated
- Severity of symptoms
- Frequency of symptoms
- Time
from
lastanalysis
episode
No
diagnostic
(skin tests, specific IgE in serum, etc)
is of value if it is interpreted without reference to medical
history
Adapted from Adverse
Reactions to Foods Committee,
Spanish Society of Allergy and Clinical Immunology

12

Medical history: (cont.)

Food : Identification of food
- How food was prepared
- Quantity ingested
- Previous tolerance
- Cross-reactions with other food
- Hidden foods, additives, contaminants
Others:
- Age at onset of symptoms
- Other factors (eg, brought on by exercise)
- Personal and family history of atopic

diseases
- Risk factors
- Manifestations: Atopic dermatitis,

13

Clinical manifestation
Cutaneus manifestation

Atopic eczema
Generally begins in early infancy
Characterized by typical distribution,
extreme pruritus, and chronically relapsing
course

14

Acute Urticaria and

Angioedema:
The most common symptoms of food allergic
reactions
The exact prevalence of these reactions is
unknown
Acute urticaria due to contact with food is also
common

Chronic Urticaria:
Food allergy is an infrequent cause of chronic
urticaria and angioedema
15

Respiratory
manifestations
Asthma
An uncommon manifestation of food allergy
Usually seen with other food-induced
symptoms

Rhinoconjunctivitis
Usually seen during positive controlled
challenge tests, but occasionally reported
by patients
16

Systemic reaction:
anaphylaxis/anaphylaxis
syndrome

Food-induced anaphylaxis
- Rapid-onset
- Multi-organ system involvement
- Potentially fatal
- Any food, highest risk:
peanut, nut, seafood, milk, egg

Food-dependent - exercise-induced
- Associated with a particular food
- Associated with eating any food
17

IgE-mediated:
GIT manifestation
Oral allergy syndrome (OAS)
Elicited by a variety of plant proteins that
cross-react with airborne allergens

Pollen allergic patients may develop

symptoms following the ingestion of vegetable
foods:
- Ragweed allergic patients: Fresh melons
and bananas
- Birch pollen allergic patients: Raw potatoes,
carrots, celery, apples, pears, hazelnuts and
kiwi

Immunotherapy for treating the pollen-

18

Food allergy prevalence in specific disorders

Disorder

Food Allergy
Prevalence

Anaphylaxis
Oral allergy
syndrome
Atopic
dermatitis
Urticaria

35 - 55 %
25 - 75% in pollen
allergic patients
35% in children (rare in
adults)
20% in acute (rare in
chronic)

Asthma

5 - 6% in asthmatic or food

19

Mixed IgE/Non-IgE mediated:

GIT allergic eosinophilic disorders
intestinal walls with eosinophils
Dysphagia, Abdominal pain, Poor
response to anti - reflux drugs
Almost 50% of patients have other atopic
diseases
Diagnosis is based on endoscopic
findings and biopsy (>15-20 eosinophils
per High Power Field)
White plaques
Biopsy:Eosinophils ++++ >20
(eosinophils)
eosinophils / HPF
Rings

Non-IgE mediated:
GIT food protein induced syndromes
(typically milk and soy induced)
Enterocolitis #
Proctocolitis
Age Onset:
Newborn

Enteropathy

Infant

Duration: 12-24 mo
< 12mo

Infant/Toddler
? 12-24 mo

CharacteFailure to thrive
Malabsorption
Bloody stools
ristics
Shock
Villous atrophy
No
sign
#systemic
Solid foods
implicated: fish, corn, chicken, turkey,
Diarrhea
vegetables Lethargy
Eosinophil
Diarrhea
Nowak-Wegrzyn et al Pediatrics
2003
Zapatero Remon L et al. Allergol Immunopathol 2005

21

Laboratory methods
Skin Prick Test
Allergens eliciting a wheal of at least
3 mm greater than the negative
control
Positive predictive accuracy

50 %

Negative predictive accuracy >

95 %
22

Prick:
non
Skinirritant
tests

Reproducible, sensitive,

Prick to prick : use raw or cooked food.

Highly recommended for
fruits &
vegetables.
Commercially prepared
extracts are
generally
inadequate due to
instability of the allergens

23

Radioallergosorbent Test
(RAST)
More convenience for patient

When skin testing is impractical

Skin disorder, drug inhibition, uncooperative

patients

To avoid systemic reactions

Prior history of
anaphylactic reaction,
severe asthma
Disadvantages

Cost, Delayed results

24

Radioallergosorbent Test (RAST)

Sensitivity similar to skin prick
tests

- Good correlation with other procedures

- Efficiency: Depends on the allergen
- Useful if discrepancy exists between

history and SPT

The use of quantitative measurements has shown to be

predictive, for some allergens, of symptomatic IgE- 25
mediated food allergy

Specific IgE & Food Allergen

J Clin Invest. 2011;121:82735

Specific IgE
Food
Value (kU/L)
Egg
2 yr old
Milk
2 yrs old
Peanut
Fish
Tree nuts

Serum IgE
7.0
2.0*
15.0
5.0**
14.0
20.0
15.0

From Sampson HA: JACI 107:891-896,2001.

* Boyano-Martinez T, Garcia-Ara C, Diaz-Pena JM, et al: Clin Exp Allergy 31:1464-1469,2001.

** Garcia-Ara C, Boyano-Martinez T, Diaz-Pena JM, et al:
27
JACI 107:185-190,2001.

28

29

Elimination diets and food challenges

Elimination diets (1 - 6 weeks):
- Eliminate suspected food/s, or
- Prescribe limited eat only diet, or
- Elemental diet
Oral food challenge testing:
- Physician supervised
- Emergency room medications must be
available
Eat an average portion of the pure food
within 5 min.
Record symptoms
Observe patient a minimum of 2 hours
30

CMA Diagnosis

History
Taking
Sign &
Symptoms

Non IgE
Mediated
IgE
Mediated
Skin
Prick Test

Specific
IgE

Atopy
Patch
Test

Elimination
&
Provocation

Diagnosis of Non Ig E mediated

food hypersensitivitty
History: Timing of Reaction slower than Ig E
mediated
Difficult to differentiate from Food
intolerance

Elimintaion Provocation test

(DBPCFC)
Ancillary test: endoscopy-biopsy
Invitro test: Atopy patch test
32

Unproven methods:
Procedures used in diagnosis
and treatment that lack
scientific credibility.
Have not been shown to have
clinical efficacy
Commercial interests

Invalid tests

Electrodermal Skin Test VEGA test - Bioresonance

Management of Food

allergy

Correct diagnosis
Treatment of reactions
Avoidance
Role of dietician
Tolerance assessment
Prevention
Follow up

Adapted from Adverse Reactions to Foods Committee.

Spanish Society of Allergy and Clinical Immunology

36

Emergency medicines
Epinephrine: drug of choice for
reactions
- Self-administered epinephrine readily available
- Train patients: Indications / technique
Antihistamines: Secondary therapy
Emergency plan in writing
- Schools, caregivers, mature siblings / friends
Emergency identification bracelet
37

Avoidance
Mainstay of treatment
Must be considered as a therapeutic approach
Risk-benefit must be assessed
- Correct diagnosis is essential
- Very restrictive diets can lead to malnutrition
Dieticians role is crucial
38

Label Reading
Milk
Milk
Artificial butter flavor, butter,
buttermilk
Casein (rennet), caseinates (calcium,
magnesium, potassium, and sodium)
Ghee
Hydrolysates (casein, milk, protein,
and whey)
Lactalbumin, lactoglobulin, lactose
(may contain), lactulose
Milk solids, milk powder, nonfat dry
milk powder
Whey
Label ingredients that may
indicate the presence of milk
protein
Chocolate
Flavorings (artificial, caramel, and
natural)
High-protein flour

Egg
Albumin
Egg (white, yolk, dried, powdered,
solids)
Mayonnaise
Label ingredients that may
indicate the presence of egg
protein
A shiny glaze or yellow baked
goods
Flavorings (artificial and natural)
Lecithin

Pediatric allergy: principles and practice. 2nd

39
edition

RECOMMENDATION
Indonesia Paediatrion Association
(IDAI)

DIAGNOSIS AND
MANAGEMENT
OF COWS MILK
PROTEIN ALLERGY

Allergy Immunology Working Group

Gastrohepatology Working Group
Nutrition and Metabolic Diseases
Working Group

Milk Formulas & Indications

No

Protein

Lactos Fat
a

1. Partially
H.

Partially N
H

2. Free
Lactose,

Indication

Prevention

0%/
N
Glucos
a
polym
er

Lact.
Intolerance
Diarhea

3. Extensive Extensiv N
H.
e casein

Prevention,
CMA

4. Extensive Extensiv N
&
e Casein

MCT55 CMA, Fat

%
Malabs

Indonesian CMA Management

Recommendation
Exclusive Breast Feeding Group
Continue Breast feeding
2013/2014
Mother: Avoid Cows Milk Protein (minimum 6
month)
Cows Milk Formula Group
Baby: Avoid Cows Milk
Replace eHF Mild-Moderate (min. 6 month)
Amino Acid Formula Severe (min. 6 month)
SOY FORMULA :
If: Cost, Availability, Taste

(start from early life with education)

AVALABILITY

Amino Acid Formula : -- +

Extensive Hydrolize Formula : +
Partiall Hydrolize Formula
:+
Cows Milk Formula
: +++
Soy Formula : ++

TASTE
Amino Acid Formula
: Verry bitter &
fishy
Extensive Hydrolize F. : Very bitter
Partiall Hydrolize F.
: Bitter
Soy Formula
: Quite nice
Cows Milk Formula : Nice

Cost of Milk Formula

Indonesian Income
per Capita: Rp.
85.000/day

Cost of Milk Formula

Europe Income
per Capita ??

9/14/2011

Soy Allergy ?
10%

````````````````````````````
````````````````````````````
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Aluminium
Kandungan AL > pada formula kedelai > formula susu
sapi dan ASI.
Formula kedelai 200 mL/kg/hari hanya <0,5 mg/kg/hari.
Msh << tolerable intake ( FAO/WHO): 1 mg/kg/hari
American Academic Pediatric (AAP): bukan masalah
keamanan bagi bayi kecuali pada bayi prematur atau bayi
dengan gagal ginjal.
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:352-61
Vandenplas Y, Castrellon P G, Rivas R, Gutierrex C J, Garcia L D, Jimenez J E, Anzo A,
Hegar B, Alarcon P. British Journal of Nutrition 2013 1:21

Soy Nutrtition?

Similar in Normal & Developmental in Term

Infants, Comparation: Soy Formula & Milk
Formula

Fitoestrogen ??
Isoflavon dalam bentuk genistein, daidzein dan glycitein
dampak perk seksual, reproduksi, neuroendokrin,
neurobehaviour, dan fungsi tyroid.
Pada kajian ilmiah: fitoestrogen dalam kedelai efek
estrogen yang lemah.
Kajian metaanalis:
pola pertumbuhan, metabolisme, tulang, reproduksi, endokrin,
sistem imun, dan fungsi neurologi sama susu formula sapi

Susu formula isolat protein kedelai

merupakan alternatif
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:352-61
Lancet 1997; 350;815-6

Fitat ??
Isolat protein kedelai mengandung fitat
sebesar 1-2%, yang dapat mengganggu
absorpsi mineral dan trace elements.
Reduksi kandungan fitat telah
dilakukan pada semua produk
formula dengan isolat protein kedelai
sehingga meningkatkan absorpsi dan
availabilitas zink, tembaga, dan mineral
lain .

Hydrolyzed formulas Taste Problem??

(Older babies Refuse at first to drink)
How can help??:
Dip the teeth in another milk (rice milk, breast milk)
just before feeding May react better to the
hydrolyzed formula
Add a small of a sweet flavor syrup to hydrolyzed
formula.
Slowly reduce the added flavoring until no ladding
any
(Don't add any of these flavorings for > a week - 10
days)
If Breastfeeding and Formula, mix hydrolyzed
formula with breast milk. Gradually increase the
amount of hydrolyzed formula

Indonesian CMA Management

Recommendation
Exclusive Breast Feeding Group
Continue Breast feeding
2013/2014
Mother: Avoid Cows Milk Protein (minimum 6
month)
Cows Milk Formula Group
Baby: Avoid Cows Milk
Replace eHF Mild-Moderate (min. 6 month)
Amino Acid Formula Severe (min. 6 month)
SOY FORMULA :
If: Cost, Availability, Taste

(start from early life with education)

Thank
you

57

Tes Rasa Formula Susu

58

Education for patient/care giver

1.Identify allergen
2. Familiarize allergen in the diet

Hidden ingredients
Labelling issues
Cross contamination (shared equipment)
Code words (Natural flavor may be cows milk)

3. Provide balance diet: Seeking

assistance : Registered dietician

Pediatric allergy: principles and practice. 2nd

edition

59

Commercial Foods that Frequently

Contain Unexpected Allergens
Foods Containing Milk
Protein
Breads and bread crumbs
English muffin
Flavored crackers
Nondairy creamer
Instant noodle cups
Sorbets
Soy cheese
Waffles
Canned fish
Baby foods with mixed
ingredients
Most mammalian milks crossreact with cow's milk (e.g.
sheep, goat)

Foods Containing Egg

Protein
Egg substitutes (i.e. egg
beaters)
Baby food spaghetti
Marshmallow pastry cream
Pasta
Waffles
Shiny baked goods (egg wash)
Wine (fined or clarified with
egg white)

Pediatric allergy: principles and practice. 2nd

60
edition

Treatment follow-up
Re-evaluate for tolerance periodically
Interval and decision to re-challenge:
- Type of food allergy
- Severity of previous symptoms
- Allergen
Ancillary testing
- Skin prick test/RAST/CAP may remain positive
- Reduced concentration specific-IgE
encouraging
61