Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel

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Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.

Section snippets

Preface

Food allergy is an immune-based disease that has become a serious health concern in the United States. A recent study1 estimates that food allergy affects 5% of children under the age of 5 years and 4% of teens and adults, and its prevalence appears to be on the increase. The symptoms of this disease can range from mild to severe and, in rare cases, can lead to anaphylaxis, a severe and potentially life-threatening allergic reaction. There are no therapies available to prevent or treat food

Definitions of food allergy, food, and food allergens

The EP came to consensus on definitions used throughout the Guidelines.

A food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.

A food is defined as any substance—whether processed, semiprocessed, or raw—that is intended for human consumption, and includes drinks, chewing gum, food additives, and dietary supplements. Substances used only as drugs, tobacco products, and cosmetics (such as lip-care products)

Natural history of food allergy and associated disorders

The EP reviewed the literature on the natural history of FA and summarized the available data for the most common food allergens in the United States: egg, milk, peanut, tree nuts, wheat, crustacean shellfish, and soy. Natural history data for fish allergy were unavailable as of the completion of the systematic literature review (September 2009). In addition, the EP sought to:

  • Identify changes in the manifestations of FA over time, as well as changes in coexisting allergic conditions

  • Identify the

When should food allergy be suspected?

Guideline 1: The EP recommends that FA should be considered:

  • In individuals presenting with anaphylaxis or any combination of symptoms listed in Table IV that occur within minutes to hours of ingesting food, especially in young children and/or if symptoms have followed the ingestion of a specific food on more than 1 occasion

  • In infants, young children, and selected older children diagnosed with certain disorders, such as moderate to severe AD, EoE, enterocolitis, enteropathy, and allergic

Management of nonacute allergic reactions and prevention of food allergy

This section of the Guidelines addresses the management and prevention of nonacute and nonsevere allergic reactions to food in individuals diagnosed with FA. Management and prevention of individuals at risk for developing FA and specific concerns about vaccination in individuals with egg allergy also are addressed.

Diagnosis and management of food-induced anaphylaxis and other acute allergic reactions to foods

This section of the Guidelines focuses on the diagnosis and management of food-induced anaphylaxis that arises through IgE-mediated immune mechanisms.

Food-induced anaphylaxis is a potentially fatal disorder and, like other forms of anaphylaxis, is increasing in incidence in industrialized countries.30, 42, 244, 245, 246, 247 Although food-induced anaphylaxis is not always easily recognized, the early recognition of specific signs and symptoms associated with a reaction, the timing of the

Acknowledgments

Primary Authors

Joshua A. Boyce, MD

Division of Rheumatology, Immunology and Allergy

Brigham and Women's Hospital

Department of Medicine Harvard Medical School

Boston, Mass

Amal Assa'ad, MD

Division of Allergy and Immunology

Cincinnati Children's Hospital Medical Center

University of Cincinnati

Cincinnati, Ohio

A. Wesley Burks, MD

Division of Allergy and Immunology

Department of Pediatrics

Duke University Medical Center

Durham, NC

Stacie M. Jones, MD

Division of Allergy and Immunology

Department of Pediatrics

References (347)

  • L. Zuidmeer et al.

    The prevalence of plant food allergies: a systematic review

    J Allergy Clin Immunol

    (2008 May)
  • A. ∗Host et al.

    A prospective study of cow milk allergy in Danish infants during the first 3 years of life. Clinical course in relation to clinical and immunological type of hypersensitivity reaction

    Allergy

    (1990 Nov)
  • S. Clark et al.

    Multicenter study of emergency department visits for food allergies

    J Allergy Clin Immunol

    (2004 Feb)
  • W.W. Decker et al.

    The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project

    J Allergy Clin Immunol

    (2008 Dec)
  • R.Y. Lin et al.

    Increasing anaphylaxis hospitalizations in the first 2 decades of life: New York State, 1990-2006

    Ann Allergy Asthma Immunol

    (2008 Oct)
  • S.H. ∗Sicherer et al.

    A voluntary registry for peanut and tree nut allergy: characteristics of the first 5149 registrants

    J Allergy Clin Immunol

    (2001 Jul)
  • H.S. Skolnick et al.

    The natural history of peanut allergy

    J Allergy Clin Immunol

    (2001 Feb)
  • J.M. Skripak et al.

    The natural history of IgE-mediated cow's milk allergy

    J Allergy Clin Immunol

    (2007 Nov)
  • H.A. Sampson et al.

    Natural history of food hypersensitivity in children with atopic dermatitis

    J Pediatr

    (1989 Jul)
  • P.A. Eigenmann et al.

    Prevalence of IgE-mediated food allergy among children with atopic dermatitis

    Pediatrics

    (1998 Mar)
  • J.H. Savage et al.

    The natural history of egg allergy

    J Allergy Clin Immunol

    (2007 Dec)
  • H.A. ∗Sampson

    Food allergy. Part 1: immunopathogenesis and clinical disorders

    J Allergy Clin Immunol

    (1999 May)
  • L.P. Shek et al.

    Determination of food specific IgE levels over time can predict the development of tolerance in cow's milk and hen's egg allergy

    J Allergy Clin Immunol

    (2004 Aug)
  • T.K. Vander Leek et al.

    The natural history of peanut allergy in young children and its association with serum peanut-specific IgE

    J Pediatr

    (2000 Dec)
  • T.D. Green et al.

    Clinical characteristics of peanut-allergic children: recent changes

    Pediatrics

    (2007 Dec)
  • D.M. Fleischer et al.

    Peanut allergy: recurrence and its management

    J Allergy Clin Immunol

    (2004 Nov)
  • J.H. ∗Savage et al.

    The natural history of peanut allergy: Extending our knowledge beyond childhood

    J Allergy Clin Immunol

    (2007 Sep)
  • J.M. ∗Spergel et al.

    Resolution of childhood peanut allergy

    Ann Allergy Asthma Immunol

    (2000 Dec)
  • D.M. Fleischer et al.

    The natural history of tree nut allergy

    J Allergy Clin Immunol

    (2005 Nov)
  • C.A. Keet et al.

    The natural history of wheat allergy

    Ann Allergy Asthma Immunol

    (2009 May)
  • C.B. ∗Daul et al.

    The natural history of shrimp hypersensitivity

    J Allergy Clin Immunol

    (1990 Jul)
  • J.H. ∗Savage et al.

    The natural history of soy allergy

    J Allergy Clin Immunol

    (2010 Mar)
  • L.M. ∗Webb et al.

    Anaphylaxis: a review of 601 cases

    Ann Allergy Asthma Immunol

    (2006 Jul)
  • H.Y. ∗Lam et al.

    Cow's milk allergy in adults is rare but severe: both casein and whey proteins are involved

    Clin Exp Allergy

    (2008 Jun)
  • S.A. Bock et al.

    Fatalities due to anaphylactic reactions to foods

    J Allergy Clin Immunol

    (2001 Jan)
  • H.A. Sampson et al.

    Fatal and near-fatal anaphylactic reactions to food in children and adolescents

    N Engl J Med

    (1992 Aug 6)
  • H. Agata et al.

    Effect of elimination diets on food-specific IgE antibodies and lymphocyte proliferative responses to food antigens in atopic dermatitis patients exhibiting sensitivity to food allergens

    J Allergy Clin Immunol

    (1993 Feb)
  • R. Lever et al.

    Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs

    Pediatr Allergy Immunol

    (1998 Feb)
  • E.H. Dauer et al.

    Clinical characteristics of eosinophilic esophagitis in children

    Ann Otol Rhinol Laryngol

    (2005 Nov)
  • C.A. Liacouras et al.

    Eosinophilic esophagitis: a 10-year experience in 381 children

    Clin Gastroenterol Hepatol

    (2005 Dec)
  • N.A. Shadick et al.

    The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study

    J Allergy Clin Immunol

    (1999 Jul)
  • V. Malik et al.

    Rhinitis due to food allergies: fact or fiction?

    J Laryngol Otol

    (2007 Jun)
  • J.W. Yunginger et al.

    Fatal anaphylactic reactions induced by peanuts

    Allergy Proc

    (1989 Jul)
  • M.J. ∗Greenhawt et al.

    Food allergy and food allergy attitudes among college students

    J Allergy Clin Immunol

    (2009 Aug)
  • P.A. Eigenmann et al.

    Prevalence of IgE-mediated food allergy among children with atopic dermatitis

    Pediatr

    (1998)
  • G. ∗Raphael et al.

    Gustatory rhinitis: a syndrome of food-induced rhinorrhea

    J Allergy Clin Immunol

    (1989 Jan)
  • S.H. ∗Sicherer et al.

    Auriculotemporal syndrome: a masquerader of food allergy

    J Allergy Clin Immunol

    (1996 Mar)
  • F.E. ∗Russell et al.

    Scombroid poisoning: mini-review with case histories

    Toxicon

    (1986)
  • H.A. Sampson

    Differential diagnosis in adverse reactions to foods

    J Allergy Clin Immunol

    (1986)
  • S.A. ∗Bock et al.

    Studies of hypersensitivity reactions to foods in infants and children

    J Allergy Clin Immunol

    (1978 Dec)
  • Cited by (0)

    Sources of funding

    Publication of this article was supported by the Food Allergy Initiative.

    Disclosure of potential conflict of interest:

    • J. A. Boyce has served on the Advisory Board of GlaxoSmithKline. He has served as a consultant and/or speaker for Altana, GlaxoSmithKline, and Merck. He has received funding/grant support from the National Institutes of Health.

    • A. Assa'ad holds, or is listed as an inventor on, US patent application #10/566903, entitled “Genetic markers of food allergy.” She has served as a consultant for GlaxoSmithKline and as a speaker for the American College of Allergy, Asthma, and Immunology, the North East Allergy Society, the Virginia Allergy Society, the New England Allergy Society, and the American Academy of Pediatrics. Dr Assa'ad has received funding/grant support from GlaxoSmithKline.

    • A. W. Burks holds, or is listed as an inventor on, multiple US patents related to food allergy. He owns stock in Allertein and MastCell, Inc, and is a minority stockholder in Dannon Co Probiotics. He has served as a consultant for ActoGeniX NV, McNeil Nutritionals, Mead Johnson, and Novartis. He has served on the speaker's bureau for EpiPen/Dey, LP, and has served on the data monitoring committee for Genentech. He has served on an expert panel for Nutricia. Dr Burks has received funding/grant support from the Food Allergy and Anaphylaxis Network, Gerber, Mead Johnson, and the National Institutes of Health.

    • S. M. Jones has served as a speaker and grant reviewer and has served on the medical advisory committee for the Food Allergy and Anaphylaxis Network. She has received funding/grant support from Dyax Corp, the Food Allergy and Anaphylaxis Network, Mead Johnson, the National Peanut Board, and the National Institutes of Health.

    • H. A. Sampson holds, or is listed as an inventor on, multiple US patents related to food allergy. He owns stock in Allertein Therapeutics. He is the immediate past president of the American Academy of Allergy, Asthma, and Immunology. He has served as a consultant for Allertein Therapeutics, the American Academy of Allergy, Asthma, and Immunology, the Food Allergy Initiative, and Schering Plough. He has received funding/grant support for research projects from the Food Allergy Initiative, the National Institutes of Health (Division of Receipt and Referral, National Institute of Allergy and Infectious Diseases, National Center for Complementary and Alternative Medicine), and Phadia AB. He is a co-owner of Herbal Spring, LLC.

    • R. A. Wood has served as a speaker/advisory board member for GlaxoSmithKline, Merck, and Dey. He has received funding/grant support from Genentech and the National Institutes of Health (National Institute of Allergy and Infectious Diseases).

    • S. H. Arshad has received funding/grant support from the National Institutes of Health and the National Institute of Health Research, UK.

    • S. L. Bahna has received funding/grant support from Genentech.

    • L. A. Beck has received funding/grant support from the American Academy of Allergy, Asthma, and Immunology, the National Eczema Association, and the National Institutes of Health.

    • C. Byrd-Bredbenner owns stock in Johnson & Johnson. She has received funding/grant support from the US Department of Agriculture, the Canned Food Alliance, and the New Jersey Department of Health and Senior Services.

    • C. A. Camargo Jr has consulted for Dey and Novartis. He has received funding/grant support from a variety of government agencies and not-for-profit research foundations, as well as Dey and Novartis.

    • L. Eichenfield has received funding/grant support from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson & Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.

    • G. T. Furuta has served as a consultant and/or speaker to Ception Therapeutics and TAP. He has received funding/grant support from the American Gastrointestinal Association and the National Institutes of Health.

    • J. M. Hanifin has served as served as a consultant for ALZA, Anesiva, Inc, Barrier Therapeutics, Inc, Milliken & Company, Nordic Biotech, Novartis Pharmaceuticals Corporation, Shionogi USA, Taisho Pharmaceutical R&D, Inc, Teikoku Pharma USA, Inc, UCB, York Pharma, ZARS, Inc, and ZymoGenetics. He has served as an investigator or received research funding from ALZA, Astellas Pharma US, Inc, Asubio Pharmaceuticals, Inc, Centocor, Inc, Corgentech, Novartis, Nucryst Pharmaceuticals, Seattle Genetics, and Shionogi USA.

    • M. Kraft has served as a consultant and/or speaker for Astra-Zeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sepracor. She has received funding/grant support from Genentech, GlaxoSmithKline, the National Institutes of Health and Novartis.

    • B. D. Levy holds, or is listed as an inventor on, US patent applications #20080064746 entitled “Lipoxins and aspirin-triggered lipoxins and their stable analogs in the treatment of asthma and inflammatory airway diseases” and #20080096961 entitled “Use of docosatrienes, resolvins and their stable analogs in the treatment of airway diseases and asthma.” He owns stock in Resolvyx Pharmaceuticals. He has served as a consultant for Bayer Healthcare and Resolvyx Pharmaceuticals. Dr Levy has received funding/grant support from the National Institutes of Health.

    • P. Lieberman has served as a consultant and/or speaker to Dey Laboratories, Novartis, Schering-Plough, AstraZenica, Merck, TEVA, Pfizer, MEDA, Alcon, Genentech, Intelliject, and the Food Allergy and Anaphylaxis Network. He is past president of the American Academy of Allergy, Asthma, and Immunology.

    • L. C. Schneider has served as a consultant/clinical advisor for the Food Allergy Initiative. She has received funding/grant support from a variety of not-for-profit research foundations, as well as Novartis and the National Institutes of Health.

    • R. A. Simon has served as a speaker for Dey Laboratories, Genentech, GlaxoSmithKline, Merck, Novartis, and the US Food and Drug Administration.

    • F. E. R. Simons holds a patent on “Fast-disintegrating epinephrine tablets for sublingual administration.” She is a past-president of the American Academy of Allergy, Asthma, and Immunology and of the Canadian Society of Allergy and Clinical Immunology. She is a member of the advisory boards of Dey, Intelliject, and ALK-Abello. She has received funding/grant support from AllerGen, the Canadian Allergy, Asthma and Immunology Foundation/Anaphylaxis Canada, and the Canadian Institutes of Health Research.

    • S. J. Teach has served as a speaker for AstraZeneca. He has received funding/grant support from the AstraZeneca Foundation, Aventis, the Child Health Center Board, the CNMC Research Advisory Council, the National Association of Chain Drug Stores Foundation, the National Institutes of Health (National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute), Novartis/Genentech, the Robert Woods Johnson Foundation, the US Centers for Disease Control and Prevention, the US Public Health Service, and the Washington, DC, Department of Health.

    The other authors have declared that they have no conflict of interest.

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