Food allergy:

Practical diagnosis
Mike Levin
Heidi Thomas
Red Cross Allergy Clinic
 Diagnosis of IgE mediated Food
allergy
• History
• Allergy testing
– Skin prick tests
– Specific IgE
– Patch tests
• Food challenges
 Questions to ask in food allergy
• Does your child have any allergies?
• What food do you think is causing the allergy?
• Was the suspected food inhaled, ingested or touched?
• Can your child eat a full helping of the following foods:
– Milk
– Eggs (cakes, whole egg, raw egg)
– Nuts etc…
• Does your child have an aversion to the suspected food? Aversion may
be allergy
• How soon after eating the food does your child have a reaction?
• How soon after eating the food did it take for the symptoms to resolve?
• What were the symptoms and how severe was the reaction?
 Allergy testing
• Skin test or specific IgE
• Suspected allergens
• Common allergens not yet encountered
• Don’t test if tolerated (but remember
delayed reactions)
• Common associations
 Common associations
• Co-sensitisation / co-reactivity more
common than cross reactivity
– Co-sensitisation / co-reactivity
• independent sensitisation to more than one
allergen
– Cross-reactivity
• reaction on exposure to a second antigen after
sensitisation to the first, because of similar
antibody binding epitopes
Egg Peanut 20 – 30 %

Milk Soy 10 (– 40) %

Peanut Tree nuts 35 – 50 %

Peanut Sesame 25 %
 Interpreting food allergy tests
• History is critical
• Food challenge is only positive in 50% of
children with positive history
– Outgrowing allergy
– Incorrect identification of food
– Non allergic cause of reaction
• Lab tests interpreted in light of the history
 SPTs vs ImmunoCAP
SPT ImmunoCAP
• Immediate results • Lab time for results
• Cheaper than in vitro • Expensive
• Can be done with fresh • Individual allergens
extracts tested or screening tests
• Performed by trained staff eg FX5 or phadiotop
in a setting with • Wide range of allergens
resuscitation equipment can be tested
• Usually more sensitive • Safe
• Contraindications: • Not influenced by skin
– Recent antihistamine disease or medication
– Demographic skin
– Extensive eczema
SKIN PRICK TESTING
 Skin prick testing
• Method is important
• Weal size correlates
with likelihood of
being clinically
allergic
• Weal size does NOT
correlate with severity
of allergic reaction
 METHOD
• Place patient in comfortable position
• Explain and reassure patient
• Use inner aspects of forearm – clean skin
• Mark skin 2cm between each allergen
• -ve (saline) & +ve (histamine) control used
• Drop minute drop of allergen where marked until
all placed - last is histamine
• Prick to skin method may be used using fresh
allergen e.g. fruit
 METHOD (cont)
• Prick with sterile lancet vertically through
skin, consistent pressure– new lancet for
each allergen
• Blot dry with tissue – do not cross-
contaminate
• Observe for 15 min
• Not to scratch - reassure
 METHOD (cont)
• Gently retract skin mark around wheal with
a ball point pen
• Measure internal diameter at widest point
and at 90 degrees to this – record on SPT
chart
• Calculate mean diameter
• Add up and divide by two
• Note any pseudopod
• If irregular shape transfer image using tape
 Sporik et al 2000
• 467 children seen in a tertiary clinic
• Skin test and food challenges on all
• Weal sizes above which all challenges
were positive (100 % PPV)
Child > 2 years Child < 2 years
Milk ≥ 8 mm ≥ 6 mm
Egg ≥ 7mm ≥ 5 mm
Peanut ≥ 8mm ≥ 4 mm
• Could have avoided about half of
challenges by using these cut-offs
 Lack, Roberts
• Weal sizes above which 95% of
challenges were positive (95 % PPV)
Child > 2 years Child < 2 years
Milk ≥ 8 mm ≥ 8 mm
Egg ≥ 6mm ≥ 6 mm
Peanut ≥ 8mm ≥ 6 mm
 Sporik et al 2000
Likelihood ratios of a positive challenge
Weal (mm) Milk Egg Peanut
1 3.1 1.4 2.0
2 3.1 1.7 2.0
3 3.8 2.8 3.4
4 5.8 3.1 6.3
5 7.3 7.3 18.0
6 13.2 12.5 16.7
7 16.2 ∞ ∞
8 ∞ ∞ ∞
Likelihood
ratios
Child with a poor /
possible history of peanut
allergy
Pre test probability 1%
(less than general
population)
Ratios
0mm 0.001 = 0%
3mm 3.4 = 4%
5 mm 18 = 18%
8mm ∞ = 100%
Likelihood
ratios
Child with a good history
of peanut allergy
Pre test probability 50%

Ratios
0mm 0.001 = 0.1%
3mm 3.4 = 70%
5 mm 18 = 93%
8mm ∞ = 100%
Likelihood
ratios
Poor history
0mm = 0%
3mm = 4%
5 mm = 18%
8mm = 100%

Good history
0mm = 0.1%
3mm = 70%
5 mm = 93%
8mm = 100%
 Specific IgE
• Variety of systems available
• Phadia ImmunoCAP
• Must have quantitative values
• Result correlates with likelihood of being
clinically allergic
• Result does NOT correlate with severity of
allergic reaction
 Interpreting food allergy tests
• Different studies give different “cut off
levels” for significance
• History is critical
• Lab tests interpreted in light of the history
 Sampson et al 1997
• 196 children
• All with atopic dermatitis
• 50 % with asthma and PAR
• 494 DBPCFC performed
• Blood analysed for specific IgE to foods
95% PPV

“Cut-off” value: 15
 Sampson et al 1997
Food 95 % PPV Likelihood ratio

Egg 6

Milk

Peanut

Fish
 Sampson et al 1997
Food 95 % PPV Likelihood ratio

Egg 6 7.2

Milk

Peanut

Fish
 Sampson et al 1997
Food 95 % PPV Likelihood ratio

Egg 6

Milk 32

Peanut 15

Fish 20
 Sampson et al 1997
Food 95 % PPV Likelihood ratio

Egg 6 7.2

Milk 32 25

Peanut 15 9.1

Fish 20 40
Sampson et al 2003
Food 95 % PPV

Egg >2 7kU/L

<2 2kU/L
Milk >2 15kU/L
<2 5kU/L
Peanut 14

Fish 20
 Interpretation
• Tests give 3 possible results
– Low
• Skin prick test 0-2 mm
• Specific IgE < 0.35 kU/L
– Medium
• Skin test 3-7 mm
• Specific IgE > 0.35 to 95 % PPV
– High
• Skin test ≥ 8 mm
• Specific IgE ≥ 95 % PPV
 Interpretation
• 3 possible outcomes
– Not allergic
• Eat the food, preferably immediately
– Possible allergy
• Food challenge needed (avoid till booked)
– Allergic
• Recommend avoidance
 Interpretation
Clinical history
Allergy test result
 Interpretation
Clinical history
Allergy test result

Low
Medium

High
 Interpretation
Clinical history
Poor Good
Allergy test result
 Interpretation
Clinical history
Poor Good
Allergy test result

Low Not allergy

Medium

High
 Interpretation
Clinical history
Poor Good
Allergy test result

Low Not allergy

Medium (Not allergy)

Food challenge
High
 Interpretation
Clinical history
Poor Good
Allergy test result

Low Not allergy

Medium (Not allergy)

Food challenge
High Allergy
 Interpretation
Clinical history
Poor Good
Allergy test result

Low Not allergy

Medium (Not allergy) Food challenge

Food challenge (Allergy)
High Food challenge Allergy
(Allergy)
 Interpretation
Clinical history
Poor Good
Allergy test result

Low Not allergy Food challenge

Medium (Not allergy) Food challenge

Food challenge (Allergy)
High Food challenge Allergy
(Allergy)
 Elimination and rechallenge

• No role for indiscriminate elimination diets

• Sensitisation does NOT mean allergy
• Guided by clinical history, lab results AND
challenge tests
• Best done by specialised centers
 Elimination and rechallenge
• Challenge
• Gold standard is double blinded cross over
• Open challenges much easier and often used
• Require medical supervision and access to
immediate emergency treatment
• Timing
• Early: to confirm diagnosis after 4-6 weeks (for
non IgE or mild reactions).
• Early milk allergy:Age 9-12 months or after
6/12 exclusion
• Guided by repeat skin and blood tests
 Challenge Dosing Schedule
Lip 10 40 200
ml ml ml

CM 5 20 100
doses ml ml ml

Observation

Time
0 15 30 45 60 75 90 48
(min)
hours
 Case History 1
• 7 year old boy
• Never eaten peanuts
• Skin test
– 0 mm Not allergy
– 5 mm Food challenge
– 8 mm Allergy
• 2 What if he has a sister with food allergy ?
• 3 What if he has a sister with peanut allergy ?
 Case History 4
• 12 year old boy
• Ate peanuts regularly
• Had vomiting and diarrhoea 12 hours after
a restaurant meal. Mom blamed peanuts.
Avoided nuts since but ate a handful of
peanuts at a party and was fine
• Skin tests to peanut
– 1mm Not allergy
– 4 mm Not allergy
– 10 mm Food challenge
 Case History 5
• 5 year old girl
• Eczema as a infant. Drank cows milk in
infancy, developed urticaria in minutes.
Avoiding since age 3. Drinking soya milk.
• Skin tests to milk
– 1 mm Food challenge
– 4 mm Food challenge
– 10 mm Allergy
 Case History 6
• 12 year old girl
• Ate shrimp at age 4. Urticaria and
wheezing within minutes. Avoided since
but had 3 accidental exposures with mild
urticaria. Last exposure 5 years ago.
• Specific IgE
– <0.35 Food challenge
– 3.5 Food challenge
– 32 Allergy