Your browser does not support the NLM PubReader view.

Go to this page to see a list of supporting browsers.

Food Allergy in Children

Article information

J Korean Med Assoc. 2009;52(11):1090-1099
Publication date (electronic) : 2009 January 10
doi : https://doi.org/10.5124/jkma.2009.52.11.1090
Sun-Hee Choi, MD, Yeong-Ho Rha, MD
Department of Pediatrics, Kyung Hee University College of Medicine E – mail: chsh0414@naver.com, yhrha@khmc.or.kr

Abstract

Abstract

Food allergy has increased in developed countries over the past 20 years and it has been estimated that food allergic reactions affect some 6∼8% of children. Food allergy is common and potentially serious problem in childhood. Adverse reaction to food could be classified into four groups: IgE-mediated food allergy; non-IgE mediated food allergy; non-allergic food hypersensitivity; and symptoms falsely assumed to be due to foods. Allergic testing is moving towards established thresholds levels of specific IgE that predict a probability of a clinical reaction and reduce the need of oral food challenge. Diagnosing and managing food allergy in children largely depends upon a thorough medical history with questions targeted to differentiate the character of the reaction for each suspected food. Investigations such as skin prick testing and specific IgE are helpful only in IgE-mediated reactions. The mainstay of management is to avoid the offending allergen. An anaphylactic reaction is an indication for self-injectable epinephrine for emergency use. Studies of allergen characterization and immunologic mechanisms are needed and should provide a better understanding of the immunopathology of food allergy and new, more specific forms of diagnosis and therapy. It is important to identify children with potentially life-threatening food allergy as life-threatening reaction can occur. A clear understanding of the manifestations of food allergy caused by both IgE- and non-IgE-related mechanisms will help the practitioner to identify children who likely have food allergy so that additional diagnostic evaluation can be performed and appropriate avoidance can be instituted.

Keywords: Food allergy; Children; Oral tolerance; Specific IgE assays; Elimination diet
Figure 1.

Schematic approach to diagnosis and management of allergy (Modified from Med Clin N Am 2006; 90: 97–127).

Immunopathology and clinical manifestations of selected food allergic disorders

History to be obtained for a subject reporting an adverse reaction

Adverse reactions to foods mimicking food allergy

References

1. Sampson HA. Food allergy. J Allergy Clin Immunol 2003;111(Suppl 2):540–547.
2. Norwak-Wegrzyn A, Sampson HA. Adverse reactions to foods. Med Clin N Am 2006;90:97–127.
3. Grundy J, Mathews S, Bateman B, Dean T, Arshad SH. Rising prevalence of allergy to peanut in children: Data from 2 sequential cohorts. J Allergy Clin Immunol 2002;110:784–789.
4. Bock SA. Prospective appraisal of complaints of adverse reactions to foods in children during the first 3 years of life. Pediatrics 1987;79:683–688.
5. Venter C, Pereira B, Voigt K, Grundy J, Clayton CB, Higgins B, Arshad SH, Dean T. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy 2008;63:354–359.
6. Kjaer HF, Eller E, Høst A, Anderson KE, Bindslev-Jensen C. The prevalence of allergic diseases in an unselected group of 6-year-old children. The DARC birth cohort study. Pediatr Allergy Immunol 2008;19:737–745.
7. Venter C, Pereira B, Grundy J, Clayton CB, Arshad SH, Dean T. Prevalence of sensitization reported and objectively assessed food hypersensitivity among 6-year-old children: a population-based study. Pediatr Allergy Immunol 2006;17:356–363.
8. Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, So-dergren E, Sigurdardottir ST, Lindner T, Goldhahn K, Dahl-strom J, McBride D, Madsen C. The prevalence of food allergy: a metaanalysis. J Allergy Clin Immunol 2007;120:638–646.
9. Hong SJ, Ahn KM, Lee SY, Kim KE. The prevalences of astham and allergic diseases in Korean children. Korean J Pediatr 2008;51:343–350.
10. Oh JW, Pyun BY, Choung JT, Ahn KM, Kim CH, Song SW, Son JA, Lee SY, Lee SI. Epidemiological change of atopic dermatitis and food allergy in school aged children in Korea between 1995 and 2000. J Korean Med Sci 2004;19:716–723.
11. Kim KE, Joeung BS, Lee KY. Prevalence of food allergy and offending foods in children with asthma. Pediatr Allergy Respir Dis (Korea) 1995;5:96–106.
12. Han YS, Chung SJ, Cho YY, Choi HM, Ahn JM, Lee SI. Analysis of the rate of sensitization to food allergen in children with atopic dermatitis. Korean J Community Nutrition 2004;9:90–97.
13. Lim DH. Epidemiology of anaphylaxis in Korean children. Korean J Pediatr 2008;51:351–354.
14. Eggesbo M, Botton G, Stigum H, Nafstad P, Magnus P. Is delivery by cesarean section a risk factor for food allergy? J Allergy Clin Immunol 2003;112:420–426.
15. Gern JE, Reardon CL, Hoffjan S, Nicolae D, Li Z, Roberg KA, Neaville WA, Carlson-Dakes K, Adler K, Hamilton R, Anderson E, Giltertson-Whites S, Tisler C, Dasilva D, Anklam K, Mikus LD, Rosenthal LA, Ober C, Gangnon R, Lemanske RF Jr. Effects of dog ownership and genotype on immune development and atopy in infancy. J Allergy Clin Immunol 2004;113:307–314.
16. Kumar R. Epidemiology and risk factor for the development of food allergy. Pediatr Annals 2008;37:552–558.
17. Lack G. Epidemiologic risks for food allergy. J Allergy Clin Immunol 2008;121:1331–1336.
18. Hourihane JO, Dean TP, Warner JO. Peanut allergy in relation to heredity, maternal diet, and other atopic diseases: results of questionnaire survey, skin prick testing, and food challenges. BMJ 1996;313:518–521.
19. Zeiger RS, Heller S. The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance. J Allergy Clin Immunol 1995;95:1179–1190.
20. Sicherer SH, Furlong TJ, Maes HH, Desnick RJ, Sampson HA, Gelb BD. Genetics of peanut allergy: a twin study. J Allergy Clin Immunol 2000;106:53–56.
21. Sicherer SH, Leung DYM. Advances in allergic skin disease, anaphylaxis, and hypersensivity reactions to foods, drugs, and insects in 2008. J Allergy Clin Immunol 2009;123:319–327.
22. Hill DJ, Kosking CS, de Benedictis, Orange AP, Diepgen TL, Bauchau V. EPAAC Study Group. Confirmation of the association between high levels of immunoglobulin E food sensitization and eczema in infancy: an international study. Clin Exp Allergy 2008. 38. 161–168.
23. Eigenmann PA, Sicherer SH, Borkowski TA, Cohen BA, Sampson HA. Prevalence of IgE-mediated food allergy among with atopic dermatitis. Pediatrics 1998;101:8.
24. Sampson HA. Update on food allergy. J Allergy Clin Immunol 2004;113:805–819.
25. Jenkins JA, Griffiths-Jones S, Shewry PR, Breiteneder H, Mills EN. Structural relatedness of plant food allergens with specific reference to cross-reactive allergen: an in silico analysis. J Allergy Clin Immunol 2005;115:163–170.
26. Poole JA, Barriga K, Leung DY, Hoffman M, Eisenbarth GS, Rewers M, Norris JM. Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics 2006;117:2175–2182.
27. Hsieh KY, Tsai CC, Herbert Wu CH, Lin RH. Epicutaneous exposure to protein antigen and food allergy. Clin Exp Allergy 2003;33:1067–1075.
28. Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy in childhood. N Engl J Med 2003;348:977–985.
29. van Reijsen FC, Felius A, Wauters EA, Bruijnxeel-Koomen CA, Koppelman SJ. T-cell reactivity for a peanut-derived epitope in the skin of a young infant with atopic dermatitis. J Allergy Clin Immunol 1998;101:207–209.
30. Chehade M, Mayer L. Oral tolerance and its relation to food hypersensitivities. J Allergy Clin Immunol 2005;115:3–12.
31. Sicherer SH, Sampson HA. Food allergy: Recent advances in pathophysiology and treatment. Annu Rev Med 2009;60:261–277.
32. Sampson HA. Food allergy. Part I: Immunopathogenesis and clinical disorders. J Allergy Clin Immunol 1999;103:717–728.
33. Ortolani C, Pastorello EA, Farioli L, Ispano M, Pravettoni V, Berti C, Incorvaia C, Zanussi C. IgE-mediated allergy from vegetable allergens. Ann Allergy 1993;71:47–46.
34. Blanchard C, Wang N, Rothenberg ME. Eosinophilic esophagitis: pathogenesis, genetics, and therapy. J Allergy Clin Immunol 2006;118:1054–1059.
35. Rothenberg ME. Eosinophilic esophagitis. J Allergy Clin Immunol 2004;113:11–28.
36. Sicherer SH. Food protein-induced enterocolitis syndrome: case presentations and managements lesson. J Allergy Clin Immunol 2005;115:149–156.
37. Sporik R, Hill DJ, Hosking CS. Specificity of allergen skin testing in predicting positive open food challenges to milk, egg and peanut in children. Clin Exp Allergy 2000;30:1540–1546.
39. Sampson HA. Utility of food-specific IgE concentrations in predicting symptomatic food allergy. J Allergy Clin Immunol 2001;107:891–896.
40. Clark AT, Ewan PW. Interpretation of tests for nut allergy in one thousand patients, in relation to allergy or tolerance. Clin Exp Allergy 2003;33:1041–1045.
41. Nowak-Wegrzyn A, Assa'ad AH, Bahna SL, Bock SA, Sicherer SH, Teuber SS. Adverse Reactions to Food Committee of American Academy of Allergy, Asthma & Immunology. Work Group report: oral food challenge testing. J Allergy Clin Immunol 2009;123(Suppl 6):365–383.
42. Mehl A, Rolinck-Werninghaus C, Staden U, Verstege A, Wahn U, Beyer K, Niggemann B. The atopy patch test in the diagnostic workup of suspected food-related symptoms in children. J Allergy Clin Immunol 2006;118:923–929.
43. Somer L. Food allergy: nutritional considerations for primary care providers. Pediatr Ann 2008;38:559–568.
44. Sicherer SH, Noone SA, Koerner CB, Christie L, Burks AW, Sampson HA. Hypoallergenicity and efficacy of an amino acid-based formula in children with cow's milk and multiple food hypersensitivities. J Pediatr 2001;138:688–693.
45. Wood W. The natural history of food allergy. J Pediatr 2003;111:1631–1637.
46. Skripak JM, Matsui EC, Mudd K, Wood RA. The natural history of IgE-mediated cow's milk allergy. J Allergy Clin Immunol 2007;120:1172–1177.
47. Savage JH, Matsui EC, Skripak JM, Wood RA. The natural history of egg allergy. J Allergy Clin Immunol 2007;120:1413–1417.
48. Savage JH, Limb SL, Brereton NH, Wood RA. The natural history of peanut allergy: Extending our knowledge beyond childhood. J Allergy Clin Immunol 2007;120:717–719.
49. Fleischer DM, Conover-Walker MK, Matsui EC, Wood RA. The natural history of tree nut allergy. J Allergy Clin Immunol 2005;116:1087–1093.
50. Keet CA, Matsui EC, Dhillon G, Lenehan P, Paterakis M, Wood RA. The natural history of wheat allergy. Ann Allergy Asthma Immunol 2009;102:410–415.
51. Greer FR, Sicherer SH, Burks AW. American Academy of Pediatrics, Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics 2008;121:183–191.

Article information Continued

Copyright © 2009 Korean Medical Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Figure 1.

Figure 1.

Schematic approach to diagnosis and management of allergy (Modified from Med Clin N Am 2006; 90: 97–127).

Table 1.

Immunopathology and clinical manifestations of selected food allergic disorders

Immonopathology Disorder Key feature Common trigger food
IgE antibody dependent (acute) Urticaria/angioedema Wheal, flare and edema within minute to 2h, after ingestion or by direct skin contact: food indentified as a culprit in 20% Multiple foods
  Oral allergy syndrome (pollen-food related) Immediate symptoms on contact of the raw fruit with oral mucosa: pruritis, tingling, erythema, angioedema of the lips, tongue, oropharynx, throat itching Raw fruits/vegetables
  Anaphylaxis GI symptoms in concert with cutaneous and /or respiratory manifestation with to 2h Milk, egg, soy peanuts, tree nuts, shellfish, vegetables
  Food associated exercise-induced anaphylaxis Food trigger anaphylaxis only if ingestion followed temporally by exercise Wheat, shellfish, vegetables
  Rhinitis, asthma These symptoms may accompany a food-allergic reaction but are rarely isolated or chronic symptoms  
IgE antibody associated. cell mediated (delayed onset/chronic) Atopic dermatitis Associated with food in 35% of children with moderate to severe rash: Relapsing pruritic vesiculopapular rash Milk, egg, wheat, soy
  Eosinophilic gastroenteritis Symptoms dependent on site/degree of eosinophilic inflammation. Esophagus (eosinophilic esophagitis)-dysphagia, pain, GE reflux,. Genealized-failure to thrive, pain, emesis, protein losing enteropathy Multiple foods,
Cell mediated (delayed onset/chronic) Diatary protein proctocolitis Mucus-laden, bloody stools in infants Cow milk via breast feeding
  Diatary protein enterocolitis Chronic emesis, diarrhea, failure to thrive Cow milk, soy, grains

Modified from Med Clin N Am 2006; 90: 97–127.

Table 2.

History to be obtained for a subject reporting an adverse reaction

1. Description of symptoms and signs
2. Timing from ingestion to onset of symptoms
3. Frequency with which reactions have occurred
4. Time of most recent occurrence
5. Quantity of food required to evoke reaction
6. Associated factors (activity, medication)

Adopted from Leung DYM, et al.(eds). Pediatric allergy: Principle and Practice. 1st. ed. St. Louis: Mosby, 2003: 481

Table 3.

Adverse reactions to foods mimicking food allergy

Condition Symptomatic Manifestation Mechanism
Lactose intolerance Bloating, Abdominal pain, diarrhea (dose dependent) Lactase deficiency
Fructose intolerance Bloating, Abdominal pain, diarrhea (dose dependent) Fructase deficiency
Pancreatic insufficiency, Gallbladder/liver disease Malabsorption Deficiency of Enzyme
Food poisoning Pain, fever, nausa, vomiting, diarrhea bacterial toxin in food
Scombroid fish poisoning Flushing, angioedema, abdominal pain Histidine in spoiled fish metabolized histamine
Thyamine in aged cheese Migraine Pharmacologic effects of thyramine in susceptible individual
Caffeine Tremor, cramps, diarrhea Pharmacologic effects of thyramine in susceptible individual
Auriculo-temporal syndrome Facial flush in trigeminal nerve distribution associated with spicy foods neurogenic reflex, frequently associated with trauma to trigeminal nerve
Gustatory rhinitis Profuse watery rhinorrhea associated with spicy food Neurogenic reflex
Allergy to contaminants in foods Wheal, pruritus, angioedema, coughing, vomitting IgE- mediated reactions dust mites and molds contaminating flour, Anisakis parasite in fish

Modified from Med Clin N Am 2006; 90: 97–127.