Food Allergy Cases

1. Washington State NAPNAP 2013 Spring Conference Food Allergy Cases March 11, 2013 David R. Naimi, DO Clinical Assistant Professor of Pediatrics University of Washington School of Medicine Northwest Asthma & Allergy Center

2. Introduction Undergraduate Go Dawgs! Medical School (Pomona, CA) Pediatric Residency Case Western - Rainbow Babies & Children’s Allergy/Immunology Fellowship CHOP & U Penn

3. Everett • Mt. Vernon • Yakima • Richland • Seattle • Redmond • Red Ridge • Issaquah • Renton

4. Learning Objectives Understand the clinical manifestations of food allergic disorders Appreciate the utility of tests used to diagnose food allergy Understand when to refer to an allergist and how to follow patients with food allergy Appreciate and respond to the educational needs of patients diagnosed with food allergy in regard to avoidance and treatment

5. Cases • Infant w/“mucousy”/blood streaked stools • Teenager with oral itching to certain foods • Infant with eczema • Sarah and the Cashew Cookie • Stephanie vs the Bagel • 15yo w/fatigue, h/a, occasional abd pain and loose stools • 12yo w/salmon allergy • 3yo w/hives after peanut ingestion • Crustacean allergy • 2yo w/facial rash after food ingestion • 17yo who couldn’t swallow his pill • Infant w/delayed vomiting after solid food introduction

6. Food Allergy Definitions • Adverse food reactions – any untoward reaction to food or food additive • Food allergy/hypersensitivity – adverse food reaction due to an immunologic mechanism • Example: Peanut allergy • Food intolerance – adverse reaction due to a physiologic or non-immunologic mechanism • Lactose intolerance • Caffeine

7. Differences between IgE & Non-IgE food reactions Mixed IgE/non-IgE: Eosinophilic Esophagitis & Atopic Dermatitis

8. Spectrum of Immune mediated Food Allergy IgE-Mediated Mixed Non-IgE-Mediated Skin Urticaria Atopic Dermatitis Angioedema Dermatitis herpetiformis Respiratory (isolated symptoms rare) Asthma Rhinitis Gastrointestinal GI “Anaphylaxis” Eosinophilic Celiac disease Oral Allergy gastrointestinal Infant syndrome disorders(EoE) gastrointestinal Systemic disorders -Anaphylaxis -Food-associated or exercise-induced anaphylaxis - - - - - Histamine related symptoms??? - - - - -

9. Cases • Infant w/“mucousy”/blood streaked stools • Teenager with oral itching to certain foods • Infant with eczema • Sarah and the Cashew Cookie • Stephanie vs the Bagel • 15yo w/fatigue, h/a, occasional abd pain and loose stools • 12yo w/salmon allergy • 3yo w/hives after peanut ingestion • Crustacean allergy • 2yo w/facial rash after food ingestion • 17yo who couldn’t swallow his pill • Infant w/delayed vomiting after solid food introduction

10. The infant with “mucousy” or blood streaked stools • 2mo exclusively breastfed infant • Mucousy stools w/occasional streaks of blood noted recently • Clinical history NOT consistent w/constipation. • Normal growth & feeding pattern. • Normal exam (no rectal fissures).

11. Questions to ask yourself • Diagnoses? Food protein induced proctocolitis. Major cause of colitis <12mo. >50% of infants usually exclusively breastfed • IgE or non-IgE mediated? Non-IgE • Risk of anaphylaxis? No • What is the most common cause? Cow’s Milk, often Soy • Skin or blood testing needed? No • What to advise parent? Mother to trial off of Cow’s milk/dairy +/- Soy • Is this going to improve? Yes. Usually resolves by 9-12mo

12. What if this patient were bottle fed? • Change to hydrolyzed formula (Alimentum, Neutramigen, etc…) • Consider elemental formula (Elecare, Neocate) but NOT likely needed • Consider Soy formula (however, high likelihood of problems with soy) • Consider soy as an alternative nutrient AFTER age 6mo per European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Recommendations

13. Cases • Infant w/“mucousy”/blood streaked stools • Teenager with oral itching to certain foods • Infant with eczema • Sarah and the Cashew Cookie • Stephanie vs the Bagel • 15yo w/fatigue, h/a, occasional abd pain and loose stools • 12yo w/salmon allergy • 3yo w/hives after peanut ingestion • Crustacean allergy • 2yo w/facial rash after food ingestion • 17yo who couldn’t swallow his pill • Infant w/delayed vomiting after solid food introduction

14. 12yo with oral itching with almond, fresh fruits & veggies • Began 1-2 yrs ago • Occurs w/fresh apple, pitted fruits, melons, & fresh carrot • Same symptoms w/almond • No problems w/cooked fruits & veggies • No other symptoms (no hives, respiratory symptoms, etc).

15. Oral Allergy Syndrome(aka Pollen Food syndrome) • Oral itching w/certain foods (mild lip angioedema possible) • Contact reaction in oropharyngeal mucosa • IgE mediated • Onset <5min • Raw fruits/veggies and some nuts • Heat Labile proteins (cooked foods well-tolerated) • Affects ~50% of adults w/allergic rhinitis • Rarely causes serious symptoms (<1% risk of anaphylaxis) – possible increased risk w/tree nut & peanut

16. Oral Allergy Syndrome(aka Pollen Food syndrome) • Cross-reactive allergens • BIRCH: apple, peach, apricot, cherry, and plum, pear, almond, hazelnut, carrot, celery, parsley, caraway, fennel, coriander, aniseed, • GRASS: Melon, Tomato, Orange, Lettuce, peanut • *RAGWEED: cantaloupe, honeydew, watermelon, zucchini, cucumber, banana *There is NO RAGWEED in the Pacific NW

17. How to alleviate oral allergy syndrome • Cook/heat food (20sec in microwave) • Avoid ripe fruits • Peel & wash • PO antihistamine few hrs before ingestion • Allergy immunotherapy (allergy shots)

18. Food Allergens

19. Cases • Infant w/“mucousy”/blood streaked stools • Teenager with oral itching to certain foods • Infant with eczema • Sarah and the Cashew Cookie • Stephanie vs the Bagel • 15yo w/fatigue, h/a, occasional abd pain and loose stools • 12yo w/salmon allergy • 3yo w/hives after peanut ingestion • Crustacean allergy • 2yo w/facial rash after food ingestion • 17yo who couldn’t swallow his pill • Infant w/delayed vomiting after solid food introduction

20. The infant w/eczema • 4mo infant w/eczema - present since he was “weeks” old – involving most areas of body. • Birth & developmental hx normal. Growing & feeding well w/out history of recurrent infections or chronic diarrhea. • Exclusively breastfed – mother asking if FOOD ALLERGIES are playing a role in eczema - certain foods she ingests possibly flares his skin (? dairy)

21. The infant w/eczema • Eczema only partially improved w/1% hydrocortisone regularly • Physical exam: • significant for scattered dry & minimally erythematous patches • few excoriations on cheeks, trunk, & extremities.

22. What is the relationship between eczema and food allergy? They CAN be associated … extent of this association is controversial • Potential causes of eczema • Young children (<5yo)  Food allergy +/- Env allergens • Older children & Adults  Env allergens • Rate of sensitization to foods ranges from 30-80% (varies upon population represented) • However … ACTUAL rate of confirmed food allergy is LOWER

23. The relationship between eczema and food allergy • Ingestion of food flare of patient's eczema (increased itching and redness). • IgE: min to hrs after ingestion • Non-IgE: hrs to days after ingestion • If the child eats a food regularly, then he/she may have persistent symptoms of eczema

24. IgE Mediated Food Allergy • Allergies to various seeds (e.g. sesame) seem to be increasing. • Wheat, egg, and milk sensitization more commonly associated w/ eczema in children. WEMPSS = Wheat, Egg, Milk, Peanut/Treenut, Soy, Seafood (90% of food allergy) Most likelyseverity = peanut, treenut, seeds, seafood.

25. The modern diet “Exotic foods” • Increased reported allergic reactions • Kiwi • Mango • Papaya • Seeds (sesame, poppy, mustard)

26. Too young for testing? • Foods • No ‘cut-off’ age for skin or blood testing to foods • If an infant/child has NEVER been exposed to a food (in-utero, breastmilk, etc) then sensitization may not be present • Environmental allergens • <2yo: unlikely to be sensitized to allergens outside home • Testing to indoor allergens is still appropriate for <2yo • However, for environmental allergens: skin testing & blood testing (allergen specific IgE) can LAG behind clinical symptoms

27. Testing: What would I do in this case? • Skin testing - Foods • Wheat, Egg, Milk, Peanut, Soy • Few other foods very common in mother’s diet (ie corn, seafood) • Fruits/veggies not likely common causes • Skin testing – Environmental allergens • Dust mites • Pets (if applicable) • If blood testing ordered (food specific IgE): would also obtain a total IgE

28. What NOT to do when testing for food allergy • Skin/blood testing should NOT replace taking a hx • Do NOT blindly order “food allergy panels” (This is likely to yield clinically irrelevant results & FALSE food allergy dx) • Problem: some labs charge less for “panels.” A possible exception to the above statement … • Younger children w/recalcitrant eczema • Obtaining a history of food association may be difficult • One of the FEW times I consider “screening” for food allergy. More appropriate for children <5yo

29. Skin Testing or Blood Testing?

30. Food Allergy Testing: Identifying the presence of allergen specific IgE

31. Skin testing: Epicutaneous

32. Skin testing - Interpretation • Measurements of wheal & flare, use histamine/saline controls • Prick test: >3mm wheal w/10mm flare • Read @ 15 min • Oral antihistamines, not steroids, produce false (-) tests and alter the results of skin testing • “Other” antihistamines = Ranitidine, Famotidine, Tricyclic antidepressants

33. Results of testing in this case • Egg & Milk IgE quite elevated • Egg = 7 kU/L(normal <0.35) • Milk = 10 kU/L(normal <0.35) • Food specific IgE negative (<0.35 kU/L) for all other allergens • Total IgE minimally elevated

34. Sampson HA. Food and Drug Reactions and Anaphylaxis: Utility of food-specific IgE concentrations in predicting symptomatic food allergy. J Allergy Clin Immunol 2001; 107(5): 891-896.

35. Diagnostic Decision Points for Food Specific IgE Sampson HA. J Allergy Clin Immunol 2001; 107(5): 891-896.

36. What do you do w/the results? • Demonstration of sensitization (via skin or blood test) to a food does NOT mean that the patient has clinical reactivity to that food (+) Test≠Clinical Relevance

37. Food Allergy Diagnoses • Clinical reactivity can be confirmed by oral food challenges OR food elimination diets. • Double-blind, placebo-controlled food challenge (DBPCFC) • “gold standard” … but not practical. • Open food challenges performed more often in the allergy clinic • more practical.

38. What next? • Maternal elimination of egg & milk from diet. Up to 2 wks is often enough time to determine improvement of eczema. • Refer to allergist, especially before introduction of solid foods • AVOID unnecessary food avoidance! This could cause increased sensitization too food.

39. “Will my baby grow out of his allergies?”

40. Natural history of Food Allergy Food allergies to most foods, other than fish/shellfish & peanut/treenuts, are usually outgrown

41. Following a child w/food allergy • Food allergic children should be monitored regularly by a pediatrician & allergist. • Serial testing (skin test and/or serum IgE) usually done yearly (depending on type of food & age of patient). • If clinical history & lab testing is reassuring, then an oral food challenge can be performed in controlled setting to ensure resolution of food allergy.

42. Following a child w/food allergy • Elevated initial food allergen specific IgE is assoc w/lower rate of resolution • Resolution of Atopic Derm may be a useful marker for onset of tolerance • Negative tests (skin or blood test) DO NOT guarantee loss of allergy. • IgE antibodies to a specific food can PERSIST even after clinical reactivity to that food has cleared. • Therefore, oral food challenges (often done by allergists in the office) can be helpful.

43. Food Allergy Diagnoses

44. Standard of Care for Food Allergy • Every food allergic reaction has possibility of developing into life-threatening reaction • may depend upon how much of the food is eaten • Long-standing principle = complete avoidance of even minute exposures and ready access to self-injectable epinephrine.

45. Recent data has challenged the long-standing idea of strict avoidance, instead, attempting to incorporate small amounts of the food into the diet.

46. Effect of Cooking & Digestion on Food Proteins M M I I M I L 1 L K I M 1 Processing K 2 2 L K K L Children with milk (and egg) allergy MAY often tolerate baked-milk or baked-egg products

47. BAKED GOODSChanging the Paradigm: from Strict Avoidance to a Limited Diet • 70% of children with egg allergy tolerate in baked goods • 75% of children with milk allergy tolerate in baked goods • Regular ingestion of these proteins is associated w/decreasing skin test size & milk/egg specific IgE • ? may result in development of tolerance

48. What about future vaccines? Egg Allergy & Vaccines: Vaccines that contain “significant” amounts of Egg protein: • Influenza • Yellow Fever MMR IS OK!!!

49. Egg allergy & Influenza Vaccination • Studies involve TIV, not intranasal LAIV (TIV = Trivalent Influenza Vaccine. LAIV = Live Attenuated Influenza Vaccine … “FluMist”) • Vaccine administered by provider familiar w/potential manifestations of egg allergy • Administer in setting w/emergency equip available • Observe x 30min or more • Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)--United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2012 Aug 17;61(32):613-8. • Greenhawt MJ, et al. Safe administration of the seasonal trivalent influenza vaccine to children with severe egg allergy. Ann Allergy Asthma Immunol. 2012 Dec;109(6):426-30.

50. What should you tell the mother about the introduction of future foods for her infant? • Previous recommendations for delaying intro of solid foods for purpose of preventing allergic disease in “HIGH RISK” infants is NOT EFFECTIVE • Previous AAP recommendations = delay introduction of certain highly allergenic foods in high risk children: • cow's milk until age ……………………. 12mo • eggs until age …………………………... 24mo • peanuts, tree nuts, fish, and shellfish … 36mo