Guideline sources The following summarized guidelines for the evaluation and management of food allergy are prepared by our editorial team based on guidelines from the European Academy of Allergy and Clinical Immunology (EAACI 2014). 1 2 2 2 3 4 Definition Food allergy is an adverse food-stimulated immune response initiated on exposure to a given food. 2 Epidemiology Food allergy is mostly caused by IgE-mediated antibodies (type 1 or early; 48%) and IgE- independent immune response including type IV (18%), type III (10%), and type II (6%) to specific foods (milk, eggs, wheat, fish, soy, peanuts, fish, shellfish, cherries, peaches, plums, apricots, nuts, and seeds) influenced by genetic and environmental (improved hygiene, lifestyle, diet and nutrition) factors. 2 Pathophysiology The prevalence of IgE-mediated food allergy in the United States is estimated at 10,000 in 100,000 adults. 3 Disease course https://web.pathway.md/diseases/recx9BemsByRO8E4B 1/6 6/29/23, 4:07 AM Food allergy Pathway Clinical manifestations of an immediate reaction include anaphylactic shock, urticaria, and angioedema. Late reaction food reaction symptoms include fatigue, irritability, depression, hyperactivity, insomnia, headache, poor concentration, paleness, itching limbs, involuntary bedwetting, asthma, colds, indigestion, colic, diarrhea, bloating, and skin lesions. The disease impairs quality of life necessitating lifelong prevention of the specific food. 2 Prognosis and risk of recurrence The mortality risk associated with fatal anaphylaxis is < 1%. 4 Guidelines 1. Diagnostic investigations Clinical history: obtain a detailed clinical history to evaluate patients with suspected food allergy, eliciting allergens, timing and chronicity, symptoms, severity and signs, reproducibility, known risk factors, family history, and coexisting medical problems, including other allergic diseases. B Evaluation for cofactors: assess the potential role of cofactors such as exercise, NSAIDs, omeprazole, or alcohol intake. B Specific allergy testing: Direct specific allergy testing according to clinical history, as IgE sensitization does not always predict clinically relevant food allergy. B Consider either skin prick testing or specific serum IgE testing to assess for specific allergens, depending on local availability as well as potential contraindications to skin prick testing. C Serum total IgE testing: consider obtaining serum total IgE in patients with severe eczema, a very high total IgE level suggests that positive specific IgE results should be interpreted with care, as they may represent asymptomatic sensitization. C Component-resolved diagnostic tests: consider component-resolved diagnostic tests in patients in whom skin prick test and specific serum IgE tests are inconclusive. C Oral food challenge: Perform an oral food challenge if clinical history with skin prick test and/or serum IgE results is not highly predictive. B Perform oral food challenges in a specialist setting, with emergency support immediately available. B Unconventional tests: avoid the use of unconventional tests as an alternative or complementary diagnostic tool in the workup of suspected food allergy. D 2. Medical management General principles: Identify patients at risk of severe reactions in a prompt manner. B https://web.pathway.md/diseases/recx9BemsByRO8E4B 2/6 6/29/23, 4:07 AM Food allergy Pathway Assess patients who have received adrenaline in the emergency department. B Symptomatic therapy: consider antihistamines for children and adults with acute non-life- threatening symptoms from food allergy. C Show 2 more Adrenaline autoinjector: Provide a prescription for an adrenaline autoinjector to patients with any of the following: previous anaphylaxis to any food food allergy associated with persistent or severe asthma exercise-induced food-dependent anaphylaxis. B Self-administered corticosteroids: consider providing a prescription for patient-held corticosteroids, to be administered in the case of an allergic reaction in order to prevent late- phase respiratory symptoms. C Specific immunotherapy: avoid routine clinical use of food allergen-specific immunotherapy for primary food allergy, because it is associated with risk of adverse reactions, including anaphylaxis. D Anti-IgE therapy: avoid the use of anti-IgE alone or in combination with specific immunotherapy for the treatment of food allergy. D 3. Nonpharmacologic interventions Elimination diets: Advise avoidance of dietary triggers as the key treatment in the management of food allergy. B Continue elimination diets until provocation tests are performed in patients in whom the elimination diet leads to a significant relief of symptoms. B Probiotics: avoid prescribing probiotic supplements for the management of food allergy. D 4. Specific circumstances Patients with coexisting asthma: include short-acting -agonists in the management plan for all patients with coexisting asthma, to be initiated for bronchospasm after adrenaline has been given. B Patients with cow's milk allergy: advise the consumption of extensively hydrolyzed cow's milk formulas in patients with cow's milk allergy, especially in infants and young children. Consider advising amino acid formulas, especially for the subgroup of patients with more severe symptoms. A Pediatric patients: avoid prescribing soy formulas before 6 months of age and at any age in the presence of gastrointestinal symptoms. From 6 to 12 months, consider it on a case-by- case basis. D 5. Patient education https://web.pathway.md/diseases/recx9BemsByRO8E4B 3/6 6/29/23, 4:07 AM Food allergy Pathway General counseling: educate patients and caregivers regarding which foods should be avoided, give practical advice on avoidance measures, and provide teaching on how to recognize and treat allergic reactions. B 6. Follow-up and surveillance Assessment of treatment response: perform oral food challenges at regular intervals in order to assess achievement of tolerance. B Indications for dietitian referral: refer patients on long-term elimination diets to a dietitian for appropriate counseling. B Indications for specialist referral: refer patients with eosinophilic esophagitis to an allergist/immunologist for diagnostic evaluation. B Clinical findings Symptoms Past medical history Abdominal pain Allergic reactions Chronic diarrhea Anaphylaxis Dizziness Asthma Dysphagia Atopic dermatitis Itching in the mouth Atopy Itchy nose, mouth, eyes, throat, skin Integument exam Nausea Angioedema Raised, itchy red rash Sneezing Swelling Vomiting Respiratory exam Dyspnea Wheezing References 1. Muraro A, Werfel T, Hoffmann-Sommergruber K et al. EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy. 2014 Aug;69 8 1008 25. Open 2. Wioletta Agnieszka Zukiewicz-Sobczak, Paula Wr blewska, Piotr Adamczuk et al. Causes, symptoms and prevention of food allergy. Postepy Dermatol Alergol. 2013 Apr;30 2 113 6. Open 3. Christopher M Warren, Jialing Jiang, Ruchi S Gupta. Epidemiology and Burden of Food Allergy. Curr Allergy Asthma Rep. 2020 Feb 14;20 2 6. Open https://web.pathway.md/diseases/recx9BemsByRO8E4B 4/6 6/29/23, 4:07 AM Food allergy Pathway 4. Paul J Turner, Elina Jerschow, Thisanayagam Umasunthar et al. Fatal Anaphylaxis: Mortality Rate and Risk Factors. J Allergy Clin Immunol Pract. Sep-Oct 2017;5 5 1169 1178. Open 5. Muraro A, Halken S, Arshad SH et al. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy. 2014 May;69 5 590 601. Open 6. Pajno GB, Fernandez-Rivas M, Arasi S et al. EAACI Guidelines on allergen immunotherapy: IgE- mediated food allergy. Allergy. 2018 Apr;73 4 799 815. Open 7. American Academy of Pediatrics. Choosing Wisely AAP recommendations. Choosing Wisely. 2014. Open 8. Gideon Lack. Update on risk factors for food allergy. J Allergy Clin Immunol. 2012 May;129 5 1187 97. Open 9. Ruchi S Gupta, Christopher M Warren, Bridget M Smith et al. Prevalence and Severity of Food Allergies Among US Adults. JAMA Netw Open. 2019 Jan 4;2 1):e185630. Open 10. Jessica Savage, Christina B Johns. Food allergy: epidemiology and natural history. Immunol Allergy Clin North Am. 2015 Feb;35 1 45 59. Open 11. Ruchi S Gupta, Christopher M Warren, Bridget M Smith et al. The Public Health Impact of Parent- Reported Childhood Food Allergies in the United States. Pediatrics. 2018 Dec;142 6):e20181235. Open 12. Sheriene Moussa Afify, Isabella Pali-Sch ll. Adverse reactions to food: the female dominance A secondary publication and update. World Allergy Organ J. 2017 Dec 27;10 1 43. Open 13. Elissa M Abrams, Scott H Sicherer. Diagnosis and management of food allergy. CMAJ. 2016 Oct 18;188 15 1087 1093. Open 14. American Academy of Allergy, Asthma & Immunology. Choosing Wisely AAAAI recommendations. Choosing Wisely. 2012. Open 15. Jihyun Kim, Eunyoung Chang, Youngshin Han et al. The incidence and risk factors of immediate type food allergy during the first year of life in Korean infants: a birth cohort study. Pediatr Allergy Immunol. 2011 Nov;22 7 715 9. Open 16. David M Fleischer, Edmond S Chan, Carina Venter et al. A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract. 2021 Jan;9 1 22 43.e4. Open 17. Cristina A Carter, Michael Pistiner, Julie Wang et al. Food Allergy in Restaurants Work Group Report. J Allergy Clin Immunol Pract. 2020 Jan;8 1 70 74. Open 18. Hugh A Sampson, Seema Aceves, S Allan Bock et al. Food allergy: a practice parameter update- 2014. J Allergy Clin Immunol. 2014 Nov;134 5 1016 25.e43. Open 19. Margitta Worm, Imke Reese, Barbara Ballmer-Weber et al. Guidelines on the management of IgE- mediated food allergies: S2k-Guidelines of the German Society for Allergology and Clinical Immunology DGAKI in collaboration with the German Medical Association of Allergologists AeDA , the German Professional Association of Pediatricians BVKJ , the German Allergy and Asthma Association DAAB , German Dermatological Society DDG , the German Society for Nutrition DGE , the German Society for Gastroenterology, Digestive and Metabolic Diseases DGVS , the German Society for Oto-Rhino- Laryngology, Head and Neck Surgery, the German Society for Pediatric and Adolescent Medicine DGKJ , the German Society for Pediatric Allergology and Environmental Medicine GPA , the German Society for Pneumology DGP , the German Society for Pediatric Gastroenterology and Nutrition https://web.pathway.md/diseases/recx9BemsByRO8E4B 5/6 6/29/23, 4:07 AM Food allergy Pathway GPGE , German Contact Allergy Group DKG , the Austrian Society for Allergology and Immunology GAI , German Professional Association of Nutritional Sciences VDOE and the Association of the Scientific Medical Societies Germany AWMF . Allergo J Int. 2015;24 256 293. Open https://web.pathway.md/diseases/recx9BemsByRO8E4B 6/6