Characteristics of Food Allergic Reactions in United States Restaurants

Improving Clinical Practice Through Patient Registries in Allergy and Immunology

Patient registries are a mechanism for collecting data on allergic and immunologic diseases that provide important information on epidemiology and outcomes that can ultimately improve patient care. Key criteria for establishing effective registries include the use of a clearly defined purpose, identifying the target population and ensuring consistent data collection. Registries in allergic diseases include those for diseases such as inborn errors of immunity (IEI), food allergy, asthma and anaphylaxis, pharmacological interventions in vulnerable populations, and adverse effects of pharmacologic interventions including hypersensitivity reactions to drugs and vaccines. Important insights gained from patient registries in our field include contributions in phenotype and outcomes in IEI, the risk for adverse reactions in food-allergic patients in multiple settings, the benefits and risk of biologic medications for asthma during pregnancy, vaccine safety, and the categorization and genetic determination of risk for severe cutaneous adverse reactions to medications. Impediments to the development of clinically meaningful patient registries include the lack of funding resources for registry establishment and the quality, quantity, and consistency of available data. Despite these drawbacks, high-quality and successful registries are invaluable in informing clinical practice and improving outcomes in patients with allergic and immunological diseases.

The clinical burden of food allergies: Insights from the Food Allergy Research & Education (FARE) Patient Registry

Background

Food allergies are serious and potentially life-threatening, and often place a large burden on patients and their caregivers, including impacts on quality of life.

Objective

To assess the real-world patient burden of food allergies, using self-reported data available from the Food Allergy Research & Education (FARE) Patient Registry (NCT04653324).

Methods

The FARE Patient Registry is voluntary and captures real-world experiences of adults and pediatric patients in the United States, and their caregivers, through a series of surveys assessing patient health and experiences with food allergies. Self-reported data were descriptively analyzed.

Results

The FARE study cohort included 5587 patients with food allergies; 82% had multiple food allergies and 62% were aged <18 years. About half of the patients were first diagnosed by an allergist/immunologist (53%), most commonly with a skin prick test (71%) or a serum immunoglobulin E test (62%). This analysis found that food allergies (most commonly peanut [66%], tree nuts [61%], egg [43%], and milk [37%]) impart a large clinical burden on patients, many of whom experience food-related allergic reactions and comorbidities. Many patients experienced >1 food-related allergic reaction per year (42%), with 46% experiencing food-induced anaphylaxis. Half of all food-related allergic reactions occurred at home. Accidental exposures to food allergens were experienced by 77% of patients. The most common allergic comorbidities reported by patients with food allergies were atopic dermatitis (48%), asthma (46%), and allergic rhinitis (39%). The clinical burden of food allergies were found to be greater in patients with multiple food allergies, and different for adults versus pediatric patients.

Conclusion

This is the first study to assess patient experience and disease burden information from patients contributing to the FARE Patient Registry, thus providing a unique insight into the lives of patients in the United States with food allergies. These insights may assist clinicians and other public health stakeholders in the management of patients with food allergies.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Socializing practices of Irish children and adolescents with food allergy: A prospective study

Background

Food is an integral part of social activities; because of fear of accidental reaction, children with food allergy (FA) are at risk of exclusion or oversupervision at these events. The extent of adaptive exclusion behaviors is poorly defined. Families attending our service are encouraged to socialize and taught to minimize risk and avoid accidental reactions.

Objective

The aim of this study was to establish the social practices and eating-out habits of children and adolescents with FA who are already attending an allergy clinic.

Methods

Irish children, aged 2 to 16 years, with confirmed FA were recruited as part of a parallel prospective observational study titled Recording Accidental Allergic Reactions in Children and Teenagers (ReAACT). Information on social activities and eating out habits was collected prospectively.

Results

A total of 531 children were enrolled. The majority attended age-appropriate social activities; 97% of the 5- to 12-year-olds went to birthday parties and 85% visited friends' houses. More nonparticipators had previous anaphylaxis (relative risk [RR] = 1.44; 95% CI = 0.97-2.14; P = .06) and peanut allergy (RR = 1.19; 95% CI = 0.99-1.42; P = .06). Among adolescents, 94% visited friends' homes, but only 12% had been away from home alone. Overall, 523 participants (98.5 %) visited food establishments, whereas 4.6% did not eat out in any food establishment; these participants were significantly more likely to be adolescents (RR = 3.27; 95% CI = 1.65-7.48; P = .0001).

Conclusion

Overall, Irish children with FA are "living with allergy." There was a trend toward decreased participation among adolescents. Future interventions should target this group specifically.

Food Immunotherapy: Dissecting Current Guidelines and Navigating the Gray Zone

Food allergy is a common, chronic disease that is burdensome for patients and families, with multiple dietary and social limitations and a significant psychological impact stemming from the fear of accidental exposures and potentially severe, life-threatening reactions. Until recently, the only management option consisted of strict food avoidance. Food allergen immunotherapy (food AIT) has emerged as an alternative, active intervention to strict food avoidance, with a multitude of research studies supporting its efficacy and good safety profile. Food AIT results in a raise of allergenic threshold, which provides several benefits to food-allergic patients, including protection from accidental exposures, potentially decreased severity of allergic reactions on unintentional exposures, and improvement in quality of life. In the last few years, multiple independent reports have been published proposing strategies to implement food oral immunotherapy in U.S. clinics, although formal guidelines are currently lacking. Because food immunotherapy is gaining traction, popularity, and interest among both patients and health care providers, many physicians look for guidance on how to implement this intervention in their daily practice. In other parts of the world, use of this treatment has prompted the development of various guidelines from allergy societies. This rostrum discusses currently available guidelines on food AIT from different areas of the world, describes and comments on their similarities and differences, and highlights unmet needs in this area of therapy.

Food allergy risks and dining industry – an assessment and a path forward

Food allergies have increased in prevalence over the last few decades and continue to grow. Consumption of even trace amounts of common foods can cause a rapid allergic reaction (generally within minutes) which can be mild to severe to even life-threatening. Eating at restaurants poses a risk of allergic reactions for those with food allergies due to inadequate, inconsistent labeling of allergens in foods. Here, we review food labeling rules and practices in the restaurant industry and compare and contrast it with food labeling for prepackaged foods. We review global and United States trends, and provide a brief historical overview. The paper describes the key legal and economic motivations behind restaurant food labeling. Next, we describe novel risk-driven policies and new biotechnologies that have the potential to change food labeling practices worldwide. Finally, we outline desirable federal regulations and voluntary information disclosures that would positively impact the public health aspects of restaurant food labeling and improve the quality of life for people with severe food allergies.

Accidental allergic reactions to food in adolescents and adults: An overview of the factors involved and implications for prevention

Accidental allergic reactions to food are one of the major problems in adult patients diagnosed with food allergy. Such reactions occur frequently, are often severe and are associated with higher medical and non-medical costs. The aim of this Perspective is to provide insight into the different factors involved in the occurrence of accidental allergic reactions and to present an overview of practical implications for effective preventive measures. Several factors affect the occurrence of accidental reactions. These factors are related to the patient, health care, or food. The most important patient-related factors are age, social barriers to disclosing their allergy and non-adherence to the elimination diet. With regards to healthcare, the degree to which clinical practice is tailored to the individual patient is an important factor. The major food-related factor is the absence of adequate precautionary allergen labeling (PAL) guidelines. Since many factors are involved in accidental allergic reactions, different preventive strategies are needed. It is highly recommended that health care be tailored to the individual patient, with regard to education about the elimination diet, support on behavioral and psychosocial aspects, usage of shared decision-making and taking into account health literacy. In addition, it is crucial that steps are taken to improve policies and guidelines for PAL.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

BACKGROUND

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).

OBJECTIVE

We sought to investigate the setting, management, and severity of pediatric FIA.

METHODS

We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.

RESULTS

We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.

CONCLUSIONS

Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Accidental Reactions to Foods: Frequency, Causes, and Severity

Purpose of Review

In this review, we present the epidemiology of food allergy and allergic reactions to foods using studies that have been published over the past decade. We review these allergic reactions — how they differ by food trigger, geographic region, demographic distribution, setting, and severity.

Recent Findings

The rising prevalence of food allergy and persistent accidental allergic reactions to foods in various settings remains a worldwide concern. Differences in global prevalence, food triggers for reactions, and severity of accidental reactions may be explained by diversity in diets and food labeling legislation. A number of studies are highlighted that describe the unique challenges and risk factors that contribute to accidental reactions in restaurants and schools, as well as the efforts that have been made to improve safety and outcomes in these settings.

Summary

Food allergy prevalence has demonstrated significant variations between regions and age groups. Despite best efforts by individuals, physicians, and legislative bodies to improve safety for food allergic individuals, accidental reactions to foods still occur and can result in fatalities.

Fatal Food Anaphylaxis: Distinguishing Fact From Fiction

Although there is a general perception that the prevalence of food allergy is increasing, data supporting this are limited. Food is the least common cause of fatal anaphylaxis, and fortunately, it is a very rare event; however, it is also unpredictable. There is widespread consensus that severe reactions cannot be predicted in a clinically meaningful way. Certain food triggers are more frequently associated with fatal anaphylaxis than others. In observational studies, peanut and tree nuts account for at least 30% to 50% of fatalities, with seafood and cow's milk also associated with fatal reactions. Fatal food-induced anaphylaxis is most likely to occur during adolescence and young adulthood, although the reasons for this are unclear. International guidelines agree that intramuscular (IM) epinephrine is the treatment of choice for managing food-triggered anaphylaxis and has a good safety profile when given by the IM route. However, fatalities still occur despite the timely administration of epinephrine. Food-allergic individuals must navigate a world that requires daily vigilance for allergens and preparedness for allergic reactions. Although the actual risk of fatal reactions is minimal, it is not zero, and severe reactions are unpredictable. Clinicians need to help patients better understand the very low but real risk of fatal reaction and enable them to lead as normal a life as possible through appropriate education, safety netting, and risk reduction.

Recognition and Management of Food Allergy and Anaphylaxis in the School and Community Setting

Given the increasing prevalence of food allergy, schools and food service establishments must have procedures in place to accommodate those with the condition. Training staff on allergy management has been shown to improve knowledge and skills, although more research is needed to better understand its benefits. Furthermore, although there are challenges involved in maintaining unassigned stock epinephrine programs, they have the potential to reduce morbidity and mortality associated with anaphylaxis by improving access to potentially life-saving medication. Finally, food bans in schools may not be an effective part of food allergy management, and other measures should be considered instead.