Food Allergy – Diagnosis, Management & Considerations for College Campuses

S. Shahzad Mustafa, MD, FAAAAI

Disclosures Speaker’s bureau Genentech, Teva

Consultant Genentech, Teva

Outline Definitions Diagnosis Management Considerations for college campuses

James Daly - Author

“You cannot be distracted by the noise of misinformation.”

Definition of a Food Allergy “An adverse health effect arising from a specific immune

response that occurs reproducibly on exposure to a specific food.”

Boyce. JACI 2010; 126: 1105.

Allergy Versus Intolerance

Allergy IntoleranceRequires sensitization Can occur in absence of sensitization

Validated diagnostic testing Minimal validated diagnostic testing

Reproducible reactions Reactions can occur inconsistently

Dose independent Frequently dose dependent

Caused by an individual allergen Can be caused by a class effect

Cannot block with pre-treatment Validated pre-treatment regimens

Desensitization protocols Desensitization not possible

Can lead to death Typically very little mortality

Prevalence Food allergy affects 3-6% of children and ~3% of adults in

the United States Self reported prevalence ranges from 20-35% Over-diagnosis by physicians as high as 80%

Rona. JACI 2007; 120: 638.

Over-Diagnosis of Food Allergy

Fleischer. J Peds 2011; 158(4): 578.

Quality of Life Associated with Food Allergy 70% reported significant effects on social events 60% reported significant effects on meal preparation 40% reported a significant increase in overall stress levels 34% reported an effect on school attendance 10% chose to home school their children

Bollinger. Ann All Asthma Imunol 2006. 96: 415. Springston. Ann All Asthma Immunol 2010. 105: 287.

Diagnosis

Oral FoodChallenge

Diagnosis - History Common complaints NOT

suggestive of an IgE mediated mechanism Isolated rhinitis Isolated cough/asthma Chronic abdominal discomfort Isolated reflux/heartburn Chronic urticaria Fatigue Reactions occur inconsistently Reactions occur only with

larger doses Ongoing mild to moderate

atopic dermatitis/eczema

Food Allergy & Atopic Dermatitis

Boyce. JACI 2010; 126: 1105.

Common Food Allergens

Pediatrics AdultsFood %

Cow’s milk 2.5

Egg white 1.5

Peanut 1.0

Tree nuts 0.5

Wheat 0.4

Soy 0.4

Shellfish 0.1

Finned fish 0.1

Sesame 0.1*

Food %

Peanut 0.6

Tree nuts 0.6

Shellfish 2.0

Finned fish 0.4

Sesame 0.1*

Boyce. JACI 2010; 126: 1105.

Diagnostic Tools Skin prick testing and specific IgE testing (RAST,

ImmunoCAP, etc) indicate the presence of IgE antibody Skin prick testing and specific IgE testing do NOT prove

clinical reactivity Food allergy requires the presence of IgE antibody AND

clinical reactivity Upwards of 50-60% of individuals have presence of IgE in

the absence of clinical reactivity

Celik-Bilgli. Clin Exp All 2005; 35(3): 268.

Skin Prick Testing

A negative skin test makes allergy very unlikely Less than 5%

The likelihood of a true allergy increases with the size of the reactions > 8 mm wheal = > 95% likelihood of allergy

Sampson. JACI 2001; 107: 891., Image from WebMD.com,

Specific IgE Testing

Sampson. JACI 2001; 107: 891.

Unproven Diagnostic Testing Intradermal skin testing Atopy patch testing Food IgG or IgG4

Basophil activation testing Lymphocyte stimulation testing Applied kinesiology Hair analysis Electrodermal testing Cytotoxic tests Ordering food panels of specific IgE testing is not

recommended

Diagnosis

Oral FoodChallenge

Oral Food Challenges• Performed to confirm or refute IgE mediated food allergy

or to evaluate resolution of IgE mediated food allergy Skin prick tests commonly remains reactive despite resolution

of allergy

Van Der Velde. JACI 2012; 130(5): 1136.

Safety of Oral Food Challenges Jaffe Food Allergy Institute, 2008-2010 Patients aged 8 months – 21 years of age

Lieberman J. JACI 2011; 128(5); 1120.

Total Challenges 701

Failed challenges 132 (18.8%)

Reactions limited to skin symptoms 75 (10.7%)

Reactions requiring epinephrine 12 (1.7%)

Reactions requiring 2+ doses of epinephrine 1 (0.14%)

Reactions requiring treatment in ED 1 (0.14%)

Food Pollen Syndrome Presents with oropharyngeal itching and discomfort

typically with fresh fruits and vegetables in individuals allergic to environmental allergens

Food Pollen Syndrome Mechanism is local IgE production Minimal if any risk of anaphylaxis

Clinical diagnosis Management Avoid culprit food Continue to consume culprit food Pre-treat with antihistamine Cook/heat culprit food Allergen immunotherapy to environmental allergens

Special Considerations Cow’s milk allergy Roughly 70% will tolerate baked milk products Alternatives include soy milk, coconut milk, almond milk, rice

milk Cannot safely consume goat’s milk

Egg allergy Roughly 70% will tolerate baked egg products Safe to administer influenza and MMR vaccines

Shellfish and finned fish allergy Safe to receive contrast for radiographic studies Systemic reactions with airborne exposure have been reported

Special Considerations (cont’d) Soy allergy Safe to consume soy lecithin

Tree nut allergy Nearly all will tolerate coconut No cross reactivity with seeds Reasonable to avoid certain tree nuts but consume others

Peanut allergy 95%+ will tolerate other legumes Nearly all will tolerate highly refined peanut oil Minimal if any risk with airborne exposure

Airborne Peanut Allergen

Participants consumed peanuts to simulate various conditions Cafeteria setting Sporting event Commercial airliner

Participants measured airborne protein via personal air monitors during the eating sessions with room ventilation turned off

Perry. JACI 2004; 113(5): 973.

Rick of Airborne & Contact Exposure to Peanut

Simonte. JACI 2003; 112(1): 180.

Precautionary Labeling

Hefle. JACI 2007; 120(1): 171.

Precautionary Labeling

Percentage of Products with Detectable Allergen

Hefle. JACI 2007; 120(1): 171.

Food Allergy Guidelines

Boyce. JACI 2010; 126(6): S1.

Mortality Associated with Food Allergy

Umasunthar. Clin Exp All 2013; 43: 1333.

Management Strict food avoidance Ensure nutritional needs are being met Minimize risk of reaction while maintaining adequate

quality of life Be aware of emergency action plan Carry epinephrine at all times Periodically reevaluate for tolerance

Points to Consider Unifying factors in nearly all deaths from food allergy Peanut and/or tree nut allergy Sub-optimally controlled asthma Delayed or no administration of epinephrine

Previous reactions do NOT predict future reactions No diagnostic tools to predict the severity of reactions Adolescents and college-aged students at higher risk of

reactions due to risk-taking behavior

College Survey

Greenhawt. JACI 2009; 124: 323.

Management in School and Higher Education

http://www.cdc.gov, http://www.foodallergy.org

CDC Guidelines

“A positive psychosocial climate – coupled with food allergy education and awareness

for all children, families, and staff members –can help remove feelings of anxiety and alienation

among children with food allergies.”

Communication

Student/Patient

Parents

Campus StaffAllergist

Primary Care Physician

Consensus Best Practices for Campus Collaborative, campus-wide approach Transparent and flexible process capable of meeting

student needs without being burdensome For student and campus staff

Comprehensive food allergy policy Emergency response plan Emergency response training for staff Confidentiality

http://www.foodallergy.org

Pilot Guidelines for Higher Education

http://www.foodallergy.org

Education of School Personnel Research from Houston Independent School District 62 school nurses responsible for ~61,000 students

Compared school data from 2010 and 2012 Intervention: single educational session on food allergy provide

to all personnel in 2011 Results Decreased frequency of reactions Improved availability of epi devices

Epi device/allergic child ratio = 0.185 in 2010, 0.77 in 2012

Conclusion: a single education session for school personnel was highly successful in improving the management of food allergies in the school setting

Houston Independent School District Experience.

Example Policy

Adapted from policy statement at Siena College.

Summary Although food allergies have increased in prevalence, they

are often misdiagnosed, and this has serious implications on quality of life

Management is based on food avoidance and appropriate treatment of accidental reactions with epinephrine

Management must account for unique properties of individual food allergens

Management on campus should be based upon risk assessment, communication, education, and cooperation

Thank You

shahzad.mustafa@rochesterregional.orgwww.facebook.com/AIRRochesterGeneral