An internet-based survey on the circumstances of food-induced reactions following the diagnosis of IgE-mediated food allergy

The confidence and competence of primary school staff to administer an adrenaline auto-injector

School teachers are often inadequately prepared to use an adrenaline auto-injector (AAI), resulting in potentially dangerous treatment delays. The purpose of this study was to assess the observed competence, and self-reported confidence, of primary school teachers in the Republic of Ireland (RoI) to use an AAI. An evaluation of whether there was a link between confidence and competence was also assessed. Teachers from four primary schools in the RoI completed a questionnaire to assess their prior level of experience, training, and confidence levels with AAI administration. The four steps in administrating trainer AAI to a mannequin simulator were then assessed. A total of 61 teachers participated (out of a population of 80). The mean self-reported confidence was 1.82 out of 5 (SD = 0.96). There was no significant difference in confidence between trained and untrained participants (U = 240.5, NS). Participants who had received AAI administration training performed significantly more of the steps correctly (mean = 3.85, SD = 0.95) as compared to those who had received no training (mean = 2.97, SD = 1.10; U = 180.5, p = 0.008). There was no correlation between confidence in administrating AAI and the percentage of steps in the procedure performed correctly (rho =  -0.17, NS).  Conclusion: Improvements in readiness to administer AAIs can be achieved through the application of more effective approaches to teaching clinical skills, changes to school policies and practices, and consideration of the design of AAIs in order to make their operation safer and simpler. It is important that teachers have the confidence and competence to safely administer an AAI. What is Known: • Poor ability in adrenaline auto-injector use seen across population groups-healthcare professionals, patients, carers, and school staff • Training in the use of adrenaline auto-injectors has positive impact on competency What is New: • Irish school teachers show poor levels of competency in adrenaline auto-injector use • No observed correlation between reported confidence and competency.

Occupational anaphylaxis-Data from the anaphylaxis registry

BACKGROUND

Epidemiologic data on occupational anaphylaxis is scarce, and there is a need of more knowledge about work-related anaphylactic episodes.

METHODS

Based on the data of the Anaphylaxis Registry, we identified cases related to occupational exposure and analyzed the elicitors, demographics, severity of clinical reaction and management.

RESULTS

Since 2017, 5851 cases with an information about the occupational relation of the anaphylactic episode were registered whereby 225 (3.8%) were assigned to be caused by an occupational allergen. The vast majority of these occupational anaphylaxis cases were caused by insects (n = 186, 82.7%) followed by food (n = 27, 12.0%) and drugs (n = 8, 3.6%). Latex elicited occupational anaphylaxis in only two cases. Beekeepers, gardeners, farmers, and individuals working in professions associated with food handling, for example, employees in restaurants, bakery, pastry, and cooks were most frequently affected. The comparison of the occupational insect venom-induced anaphylaxis to a group of non-occupational insect anaphylaxis in adults (n = 1842) revealed a significant younger age in occupational anaphylaxis (46 vs. 53 years), a predominance of bee-induced cases (38% vs. 17%), and a higher rate of venom immunotherapy in a primary care setting (3.3% vs. 1.3%, p = .044). In the occupational- versus non-occupational adults with food-induced anaphylaxis atopic dermatitis as concomitant atopic disease was observed more frequently (n = 486; 20% vs. 10%), although this was not significant.

CONCLUSION

Our data demonstrate the impact of venom allergy in work-related anaphylaxis. Foods and drugs are less frequently elicitors, and latex-induced occupational anaphylaxis was rare. More data are needed to determine risk factors associated with occupational anaphylaxis.

Factors influencing accidental food allergic reactions in schools and preschools

BACKGROUND

Children spend a large proportion of their childhood in schools. In Ireland, there is no government policy on the management of food allergy (FA) in schools or preschool childcare settings (CCS). There is limited data worldwide on rate of accidental allergic reactions (AARs) within these settings.

AIM

The aim of this paper is to report the management of FA and the incidence of AARs in Irish school or preschool CCS.

METHODS

A prospective observational study was established, enrolling children aged 2 to 16 years with confirmed FA. Participants were contacted at three monthly intervals for 1 year to report AARs to food. Data pertaining to schools and preschool CCS is reported here.

RESULTS

A total of 521 children (402 attending school and 119 attending preschool CCS) were enrolled. The annualised incidence of AARs in school was 4.5% (95% CI 2.6-7.0) and in preschool CCS 5% (95% CI 1.8-11.1); 6 of 7 of the nut reactions occurred in schools banning nuts. Half (3/6) of the preschool reactions were to cow's milk; 174/521 (33%) children did not provide their individualised allergy action plan (AAP). Four out of 18 (22%) AARs in school were anaphylaxis and none were administered adrenaline by school staff.

CONCLUSION

The incidence of AARs in this Irish cohort was found to be equivalent to the international experience. However, many of the recorded reactions identified in this study were likely avoidable. Preparation for AARs needs optimising. The ineffectiveness of "nut bans" remains unrecognised. Promoting milk and egg allergy resolution in infancy would likely reduce preschool- and school-based reaction numbers.

Preventing food allergy fatalities

Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.

Effects of training on teachers' food allergy and anaphylaxis management self-efficacy levels

BACKGROUND

Children are affected by food allergies more than adults, so teachers have the most significant responsibility for food allergy management in schools.

OBJECTIVE

To determine the effect of food allergies and anaphylaxis management training on Turkish teachers' self-efficacy.

MATERIAL AND METHODS

In this study, 90 teachers were selected using convenience sampling. Data were collected before and immediately after the training on School Personnel's Self-Efficacy in Managing Food Allergy and Anaphylaxis at School Scale. A training program that consisted of 60-minute sessions was conducted. Data were evaluated using the paired samples t-test.

RESULTS

There was a significant difference between the teachers' self-efficacy levels before (22.76±8.94) and after the training (32.81±6.09), and self-efficacy levels significantly increased (p < .05).

CONCLUSIONS

The training increased the teachers' self-efficacy in managing food allergies and anaphylaxis.

Evaluating the Food Allergy Passport: A Novel Food Allergy Clinical Support Tool

BACKGROUND

The prevalence of pediatric food allergy (FA) has increased in the past 2 decades. The previous literature suggests that FA presents burdens, both economically and psychosocially, to children and their caregivers, especially families in lower-income strata. Using data from a previously published needs assessment, the Food Allergy Management in Low-Income Youth study, the FA Passport and Workbook tools were developed to address identified needs.

OBJECTIVE

This study evaluated the utility of the FA Passport in helping families insured by Medicaid to manage FA better and improve quality of life.

METHODS

Families insured through Illinois Medicaid were recruited from two Chicago-based allergy clinics. Caregivers of children with FA completed a pretest evaluating knowledge, attitudes, beliefs, and practices regarding FA management. A clinician guided caregivers through the FA Passport. The caregivers then completed a posttest immediately afterward and again 3 months later. Changes were evaluated from baseline responses and direct feedback was elicited about the tool.

RESULTS

The FA Passport successfully improved caregiver-reported confidence with epinephrine autoinjector use (from 69% to 93%), caregiver anaphylaxis recognition (from 66% to 73%), and reported quality of life, and it nearly doubled caregiver comfort regarding leaving the child in the care of others (from 40% to 75.7%). Caregivers rated the FA Passport tool as extremely helpful overall (9.4 out of 10).

CONCLUSIONS

The FA Passport is a novel FA clinical support tool that addresses barriers to proper FA management described in previous studies. It proved effective at improving caregiver comfort with regarding leaving the food-allergic children with other caregivers, increasing FA knowledge, and improving the quality of life in families affected by FA.

Airborne anaphylaxis: highlighting an invisible enemy

PURPOSE OF REVIEW

Airborne anaphylaxis is a rare disorder defined by the occurrence of anaphylactic reactions to inhaled allergens, which may arise not only in occupational exposure but also in common settings. Foods are the most common cause of airborne anaphylaxis, even organic mixtures scents. The other important cause is represented by drugs, while in the wide range of other causes, there are often reports on unique cases. This review aims to make an overview about the potential causes of airborne anaphylaxis, by analysing what is described in literature on this topic.

RECENT FINDINGS

Concerning epidemiology, no data on specific prevalence of airborne allergy in adults are available. To date, only one study evaluated the specific prevalence of airborne allergy with anaphylaxis to foods in children, resulting in 5.9% of reactions due to exposure to aerosolized foods, compared with 78% of reactions caused by food ingestion. In addition to anaphylaxis, airborne-related reactions may also present with symptoms such as rhino-conjunctivitis, wheezing, dyspnoea and asthma.

SUMMARY

A detailed anamnesis facilitates a correct diagnosis, which allows appropriate therapeutic and preventive interventions, but, similarly to rare diseases in general, only specialized doctors are able to implement it. The assumption of the approach used in emergency medicine for other causes of anaphylaxis, that is referring the patient at discharge to an allergist who will teach the basic notions to recognize symptoms and access the appropriate therapy, would allow the patient to avoid situations of serious danger.

Accidental ingestions to known allergens by food allergic children and adolescents

BACKGROUND

Accidental ingestions (AI) of food allergens in children compared with adolescents with food allergies are poorly characterized. It is suggested that AIs are higher in adolescents than children and that their reactions may be more severe, presumptively due, at least in part, to increased risk-taking behavior. We compared reported AIs in children versus adolescents.

METHODS

An online cross-sectional survey was distributed to parents of children with food allergies via Twitter, food allergy advocacy groups in the UK, South Africa, and Australia, and locally at Children's Hospital Colorado.

RESULTS

Of 558 respondents, 105 were parents of adolescents, and 453 had children <12 years. 73% (341) reported an AI since diagnosis, with 85% of adolescents having had an AI versus 70% of children (p = 0.0058). The annualized rate of AI was significantly lower in the adolescent population at 0.21 versus 0.53 in children (p = <0.0001). Although adolescents reported fewer severe reactions (2% vs. 16%, p = 0.0283), more adolescents required epinephrine administered by a medical professional for their most severe AI, (48% vs. 24%, p = 0.0378). Comparison of the two age groups is limited by the fact that many AIs in the adolescent group occurred prior to age 12. There was no significant difference between the groups as to where the food was consumed or the type of food. There was a significant difference in accidental ingestions in patients in all age groups with more than one reported food allergy; 78% of those with more than one food allergy reported a prior history of at least one accidental ingestion, compared with 59% in those with a single food allergy (p < 0.0001). Regional differences were also noted with respondents in the United States reporting 0.3 accidental ingestions a year, 0.4 in the UK, and 0.5 in other countries (p = 0.0455). The number of reactions was, on average, 27% lower (95% CI: 40, 11%) in the United States compared with the UK (p = 0.0019).

CONCLUSION

The number of severe reactions, and epinephrine need, differs in children compared with adolescents, although many of the reported reactions in both groups occurred before the age of 12. There were also regional differences with the United States reporting a lower number of AIs and less AIs per year than the other participating regions, as well as increased rates of AI in participants with more than one food allergy. Further characterization of the differences in AIs between children and adolescents, as well as between regions, is needed to assist with more patient-centered anticipatory guidance.

Food Allergy in Restaurants Work Group Report

Individuals with food allergy are at risk for accidental exposures, potentially resulting in allergic reactions that may cause significant morbidity and mortality. Dining out, including restaurants or take-out, account for a large proportion of severe reactions. Errors due to gaps in knowledge or miscommunication can easily occur on behalf of food-allergic individuals or restaurant staff, resulting in accidental exposures and allergic reactions. Improved legislation, training of restaurant staff, and practitioner-guided education are recommended to reinforce patient safety and prevent severe allergic reactions. This Work Group Report provides guidance with specific practices that practitioners may recommend, and that patients and restaurant staff may employ, for prevention and treatment of food-allergic reactions in restaurants.

Characteristics of Food Allergic Reactions in United States Restaurants

BACKGROUND

Food allergic reactions of varying severity occur in restaurants. Studies to date have shown that there are gaps in knowledge of and communication between restaurant staff and food allergic individuals.

OBJECTIVE

We sought to characterize allergic reactions in restaurants to better inform the restaurant industry, food allergic individual, and allergist so that mitigation strategies can be implemented.

METHODS

Data collected over a 2-year period from 2822 individuals in the Food Allergy Research & Education registry were analyzed using descriptive statistics.

RESULTS

Dining out accounted for the second most common location for a food allergic reaction, after one's home, and many were severe with 28.0% requiring 1 dose and 6.2% requiring 2 doses of epinephrine. Cafes, fast food establishments, and Asian restaurants were frequently implicated sites. Peanut, tree nuts, and milk were the most common inciting allergens, and tree nuts resulted in the most common use of epinephrine. Of the allergic reactions, 53.9% occurred despite conveyance of food allergy to restaurant staff, 26.6% occurred when allergens were declared on the menu, and 13.7% occurred when allergens were declared on the menu and restaurant staff were informed of a food allergy.

CONCLUSIONS

Allergic reactions in restaurants are common and can be severe. Findings presented here underscore the need for restaurant staff training and mandatory declaration of allergenic ingredients in meals. This updated knowledge will help support advocacy efforts and inform patients, allergists, and the restaurant industry on best practices for dining out to improve the quality of life for food allergic individuals.

Development of a screening questionnaire for the study of food allergy in adults

Background & aims

As far as we know, no screening questionnaire has been developed and validated for identification of adverse food reactions in Portuguese-speaking adults, as an initial approach towards the investigation of cases of possible food allergy. Thus, the objective of this study was to develop and validate a screening questionnaire of food allergy in adult Portuguese-speaking patients.

Methods

This was a multicentre, cross-sectional study using a simple random sample of 186 adults between 18 and 82 years old from various parts of the centre of Portugal. Intelligibility of the questionnaire was first assessed in 24 patients with confirmed IgE- or non-IgE-mediated food allergy, and in 24 volunteers without food allergies. The 17-item questionnaire was subsequently applied by phone to 78 food allergic patients (66 IgE-mediated and 12 non-IgE mediated) and to 60 non-food allergic volunteers, with subsequent reassessment (re-test). Face and content validity, intelligibility, construct validity, and test-retest reliability (temporal stability) were analysed.

Results

Face and content validity allowed item reduction from 30 to 17 items with adequate content validity index >0.78. Construct validity was confirmed in the 66 confirmed IgE-mediated food allergic patients, 12 non-IgE-mediated food allergic patients, and 60 non-allergic patients. Test-Retest Reliability (general temporal stability) of the test had a Spearman correlation coefficient value of 0.845 for the retest. Cohen's Kappa values for the relevant questions were greater than 0.890 for almost all items. No differences were found when sex, age, and volunteers' recruitment origin were analysed. An inverse relationship was found between reliability and retest time interval.

Conclusions

Due to the quick and easy implementation, confirmation of face, content and construct validity as well as high temporal reproducibility, this screening questionnaire may be a useful study tool for an initial approach to detection of food allergies in adults.

Food reactions during avoidance: Focus on peanut

OBJECTIVE

Peanut allergy has historically been difficult to manage, with most cases persisting into adulthood. Novel therapies for peanut allergy treatment are on the horizon, yet allergists must maintain a robust understanding of the risks and benefits of the current standard of therapy, avoidance diet.

DATA SOURCES

A comprehensive literature search using PubMed of reviews and clinical articles was performed.

STUDY SELECTIONS

Articles discussing peanut or other food-related allergic reactions, accidental exposures or anaphylaxis pertinent to avoidance diet or comparative to oral immunotherapy trials were selected.

RESULTS

Peanut remains a leading allergen associated with accidental ingestions responsible for food-related reactions, both mild and severe. Fatal reactions, however, are rare and measures such as anaphylaxis plans can significantly decrease the risk of accidental anaphylaxis. Patients may over estimate situations thought to increase risk for reactions to peanut, such as inhalation or contact through skin. In oral immunotherapy trials, the rate of anaphylaxis secondary to treatment was significantly higher than avoidance practices.

CONCLUSION

Clinicians should continue to discuss avoidance as a viable option for long-term peanut allergy management and empower patients to differentiate relevant situations in which accidental reactions might occur.

Food Hypersensitivity Reactions to Seafish in Atopic Dermatitis Patients Older than 14 Year of Age - The Evaluation of Association with Other Allergic Diseases and Parameters

Background

Seafood allergy is among one of the common food allergies. Decrease in consumption of omega-3 polyunsaturated fatty acids (PUFAs), prevalent especially in oily fish, has been proposed to contribute to the increased prevalence of allergic diseases.

Aim

The aim of this study was to evaluate, in atopic dermatitis (AD) patients, the relation between the occurrence of food hypersensitivity reaction (FHR) to seafish and the occurrence of other atopic diseases and parameters.

Methods

Complete dermatological and allergological examination was performed in patients included in the study; 332 patients were examined, with the average age 26.8 years (SD 9.2 years).

Results

The FHR to seafish was confirmed in 11% of patients. Patients suffering from FHR to seafish suffered significantly more from sensitization to fungi (in 46%), from reactions to celery (in 34%), and from persistent eczematic lesions (in 82%).

Conclusion

FHRs to seafish in AD patients are associated with persistent eczematic lesions and with the higher occurrence of sensitization to fungi and reactions to celery. The occurrence of bronchial asthma, rhinitis, positive family history, and onset of AD under 5 years of age is higher in patients with reactions to seafish, but the difference is not statistically significant.

Future Teachers' Attitudes and Knowledge Regarding the Management of the Potential Students' Life-threatening Allergic Reactions in Slovenian Schools

Introduction

Poorly developed teachers’ competences for managing children’s allergies can pose a significant problem for the wellbeing of children in the preschool and school environment. The purpose of this study is to explore the attitudes and theoretical understanding of the management of allergic reactions in children among future teachers.

Methods

A total of 572 future teachers participated in the study, 56% of whom were in the 1st year of undergraduate educational programmes, while 44% were in the 4th year. The participants answered the Teachers’ Health Competences Development – Allergy Questionnaire.

Results

The future teachers showed positive attitudes towards learning more about different child health issues. There was an average understanding of managing allergic reactions in children (59.4%; SD=16.1% success), with no statistically significant difference regarding the duration of education, science background or the students’ self-allergy. There was, however, a statistically significant difference in achievement scores between future teachers in different educational programmes (F(3,568)=6.4, p≤.000). A subgroup of future teachers exposed to basic allergy education in the 1^st year and tested again in the 4^th year showed significantly better knowledge (Mann-WhitneyU=83.0; p=.008).

Conclusion

The duration of future education, science background and self-allergy did not influence the level of knowledge regarding the management of allergic reactions in children. A basic educational programme in allergy management had a positive effect on future teachers’ knowledge of managing allergic reactions in children. Our study indicates that all future teachers should be included in specific educational programmes in order to develop adequate health competences.

Prevalence and clinical features of adverse food reactions in Portuguese adults

BACKGROUND

Only one previous study, via telephone call, on the prevalence of self-reported food allergies has been performed in Portugal, in a small sample of adults. The objective of this study was to determine the prevalence of self-reported and probable food allergy, analyze the clinical features and involved foods in Portuguese adults.

METHODS

Population-based, cross-sectional study performed in various healthcare centres from central Portugal. All 1436 randomly selected individuals (median age: 45 years, 50.6 % female) replied to a validated food allergy questionnaire by phone. Those who reported an adverse food reaction were invited to come to the hospital, where clinical history was taken, skin prick (SPT) and prick-prick skin (SPPT) tests were performed and food allergen-specific IgE levels (sIgE) were determined. An open oral challenge was performed in selected cases. Cases of positive clinical history of immediate (up to 2 h after ingestion) reaction in association with positive food sIgE levels and/or skin prick tests were classified as IgE-associated probable food allergy. Cases of positive clinical history of delayed (more than 2 h after ingestion) and negative food sIgE levels independently of positive SPT or SPPT results were classified as non-IgE associated probable food allergy.

RESULTS

The prevalence of probable food allergy in our sample was 1 %, with shellfish and fish as the most frequently implicated foods. IgE-mediated probable food allergy occurred in 0.71 % of cases, with shellfish, peanut and nuts mainly involved. Cutaneous symptoms were most frequently reported. Prevalence values and food types were discrepant between self-reported and probable food allergies.

CONCLUSIONS

The prevalence of probable food allergies in Portuguese adults is low, is mostly related to shellfish, peanut and nuts and most frequently involves cutaneous symptoms.

Fish allergy: in review

Globally, the rising consumption of fish and its derivatives, due to its nutritional value and divergence of international cuisines, has led to an increase in reports of adverse reactions to fish. Reactions to fish are not only mediated by the immune system causing allergies, but are often caused by various toxins and parasites including ciguatera and Anisakis. Allergic reactions to fish can be serious and life threatening and children usually do not outgrow this type of food allergy. The route of exposure is not only restricted to ingestion but include manual handling and inhalation of cooking vapors in the domestic and occupational environment. Prevalence rates of self-reported fish allergy range from 0.2 to 2.29 % in the general population, but can reach up to 8 % among fish processing workers. Fish allergy seems to vary with geographical eating habits, type of fish processing, and fish species exposure. The major fish allergen characterized is parvalbumin in addition to several less well-known allergens. This contemporary review discusses interesting and new findings in the area of fish allergy including demographics, novel allergens identified, immunological mechanisms of sensitization, and innovative approaches in diagnosing and managing this life-long disease.

Food allergy knowledge and attitude of restaurant personnel in Turkey

BACKGROUND

The incidence of food-induced allergic reactions is gradually increasing. Most of these allergic reactions occur in restaurants. Therefore, this study aims to investigate the awareness of restaurant personnel about food allergy.

METHODS

The training, knowledge levels on food allergy, and comfort level in providing safe food of 351 restaurant personnel in Erzurum Province, Turkey, were assessed through a face-to-face survey.

RESULTS

Among the participants, 81.5% were male (mean age 28.5 ± 8.5 years). Among them, 17.1% were chefs, 11.1% managers, 5.7% owners, and 66.1% waiters. Food allergy training was reported by 17.1% of the participants. The rates of restaurant personnel who gave the correct answers to the 4 questionnaire items, "Customers with food allergies can safely consume a small amount of that food/Food allergic reaction can cause death/If a customer is having an allergic reaction, it is appropriate to immediately serve them water to 'dilute' the allergen/Removing an allergen from a finished meal (eg, taking off nuts) may be all that is necessary to provide a safe meal for an allergic customer," which measure food allergy knowledge levels, were 46.4%, 65.7%, 55.0%, and 65.7%, respectively.

CONCLUSION

According to our study, there are gaps in the food allergy knowledge of restaurant personnel. Because preparing and serving safe meals to patients with food allergy in restaurants is important, the training of restaurant personnel in food allergy is necessary.

Food allergy: a practice parameter update-2014

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology (JCAAI). The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Food Allergy: A practice parameter update-2014." This is a complete and comprehensive document at the current time. The medical environment is a changing one, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, ACAAI, and JCAAI. These parameters are not designed for use by pharmaceutical companies in drug promotion.

EAACI food allergy and anaphylaxis guidelines: managing patients with food allergy in the community

The European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines, managing patients with food allergy (FA) in the community, intend to provide guidance to reduce the risk of accidental allergic reactions to foods in the community. This document is intended to meet the needs of early-childhood and school settings as well as providers of non-prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast-food outlets) and targets the audience of individuals with FA, their families, patient organizations, the general public, policymakers, and allergists. Food allergy is the most common trigger of anaphylaxis in the community. Providing children and caregivers with comprehensive information on food allergen avoidance and prompt recognition and management of allergic reactions are of the utmost importance. Provision of adrenaline auto-injector devices and education on how and when to use these are essential components of a comprehensive management plan. Managing patients at risk of anaphylaxis raises many challenges, which are specific to the community. This includes the need to interact with third parties providing food (e.g., school teachers and restaurant staff) to avoid accidental exposure and to help individuals with FA to make safe and appropriate food choices. Education of individuals at risk and their families, their peers, school nurses and teachers as well as restaurant and other food retail staff can reduce the risk of severe/fatal reactions. Increased awareness among policymakers may improve decision-making on legislation at local and national level.

Anaphylaxis treatment: current barriers to adrenaline auto-injector use

Anaphylaxis is a life-threatening condition that is increasing in prevalence in the developed world. There is universal expert agreement that rapid intramuscular injection of adrenaline is life-saving and constitutes the first-line treatment of anaphylaxis. The unpredictable nature of anaphylaxis and its rapid progression makes necessary the availability of a portable emergency treatment suitable for self-administration. Thus, anaphylaxis treatment guidelines recommend that at-risk patients are provided with adrenaline auto-injectors (AAIs). Despite these clear recommendations, current emergency treatment of anaphylaxis continues to be inadequate in many cases. The aim of this review is to highlight the barriers that exist to the use and availability of AAIs and that prevent proper management of anaphylaxis. In addition, we review the characteristics of all AAIs that are presently available in Europe and the USA and discuss the need for regulatory requirements to establish the performance characteristics of these devices.

Differential immuno-kinetic assays of allergen-specific binding for peanut allergy serum analysis

A label-free nanoparticle array platform has been used to detect total peanut allergen-specific binding from whole serum of patients suffering from peanut allergy. The serum from 10 patients was screened against a four-allergen panel of cat and dog dander, dust mite and peanut allergen protein Ara h1. The IgE and IgG contributions to the total specific-binding protein load to Ara h1 were identified using two secondary IgG- and IgE-specific antibodies and were found to contribute less than 50 % of the total specific protein load. The total mass of IgE, IgE and the unresolved specific-binding protein ΔsBP for Ara h1 provides a new serum profile for high-RAST-grade patients 5 and 6 with the IgG/IgE ratio of 4 ± 2 and ΔsBP/IgE ratio of 17 ± 11, neither of which is protective for the small patient cohort.

Allergic reactions to foods in preschool-aged children in a prospective observational food allergy study

OBJECTIVE

To examine circumstances of allergic reactions to foods in a cohort of preschool-aged children.

METHODS

We conducted a prospective, 5-site observational study of 512 infants aged 3 to 15 months with documented or likely allergy to milk or egg, and collected data prospectively examining allergic reactions.

RESULTS

Over a median follow-up of 36 months (range: 0-48.4), the annualized reaction rate was 0.81 per year (367/512 subjects reporting 1171 reactions [95% confidence interval: 0.76-0.85]). Overall, 269/512 (52.5%) reported >1 reaction. The majority of reactions (71.2%) were triggered by milk (495 [42.3%]), egg (246 [21.0%]), and peanut (93 [7.9%]), with accidental exposures attributed to unintentional ingestion, label-reading errors, and cross-contact. Foods were provided by persons other than parents in 50.6% of reactions. Of 834 reactions to milk, egg, or peanut, 93 (11.2%) were attributed to purposeful exposures to these avoided foods. A higher number of food allergies (P < .0001) and higher food-specific immunoglobulin E (P < .0001) were associated with reactions. Of the 11.4% of reactions (n = 134) that were severe, 29.9% were treated with epinephrine. Factors resulting in undertreatment included lack of recognition of severity, epinephrine being unavailable, and fears about epinephrine administration.

CONCLUSIONS

There was a high frequency of reactions caused by accidental and nonaccidental exposures. Undertreatment of severe reactions with epinephrine was a substantial problem. Areas for improved education include the need for constant vigilance, accurate label reading, avoidance of nonaccidental exposure, prevention of cross-contamination, appropriate epinephrine administration, and education of all caretakers.

Inadvertent exposures in children with peanut allergy

OBJECTIVES

To determine the annual incidence, characterize the severity and management, and identify predictors of accidental exposure among a cohort of children with peanut allergy.

METHODS

From 2004 to November 2009, parents of Canadian children with a physician-confirmed peanut allergy completed entry and follow-up questionnaires about accidental exposures over the preceding year. Logistic regression analyses were used to examine potential predictors.

RESULTS

A total of 1411 children [61.3% boys, mean age 7.1 yr (SD, 3.9)] participated. When all children were included, regardless of length of observation, 266 accidental exposures occurred over 2227 patient-years, yielding an annual incidence rate of 11.9% (95% CI, 10.6-13.5). When all accidental exposures occurring after study entry and patients providing <1 yr of observation were excluded, 147 exposures occurred over a period of 1175 patient-years, yielding a rate of 12.5% (95% CI, 10.7-14.5). Only 21% of moderate and severe reactions were treated with epinephrine. Age ≥13 yr at study entry (OR, 2.33; 95% CI, 1.20-4.53) and a severe previous reaction to peanut (OR, 2.04; 95% CI, 1.44-2.91) were associated with an increased risk of accidental exposure, and increasing disease duration (OR, 0.88; 95% CI, 0.83-0.92) with a decreased risk.

CONCLUSION

The annual incidence rate of accidental exposure for children with peanut allergy is 12.5%. Children with a recent diagnosis and adolescents are at higher risk. Hence, education of allergic children and their families is crucial immediately after diagnosis and during adolescence. As many reactions were treated inappropriately, healthcare professionals require better education on anaphylaxis management.

A qualitative investigation into the maternal experience of having a young child with severe food allergy

BACKGROUND

Severe food allergy has potentially life threatening consequences. Despite the significant impact on quality of life for families affected by food allergy, there is still relatively little known about the psychosocial experience in this area, especially with regards to the parenting experience.

OBJECTIVES

This study focused on the following areas of parental experience: (1) having a young child with severe food allergy; (2) perception of the effect of food allergy on family relationships; (3) managing the challenges associated with severe food allergy.

METHODS

Eight mothers of children with severe food allergy completed semi-structured interviews. Interview transcripts were analysed using Interpretative Phenomenological Analysis (IPA), a qualitative methodology.

RESULTS

Three superordinate themes emerged from the analysis: (1) Parental adjustment-re-establishing an "even keel"; (2) It's a big responsibility: Living with risk; (3) Identity and the social aspects of allergy. This article focuses on the most psychologically salient findings within each of these superordinate themes.

CONCLUSION

Mothers in this study shared similar concerns to mothers of children with other chronic illnesses. It is recommended that the experience of allergy should be viewed in the wider family context with specific consideration given to parental coping and anxiety. Services could better meet the psychological and social needs of those affected by allergy.

Variations in quality of life among caregivers of food allergic children

BACKGROUND

Pediatric food allergy is a serious health problem in the United States. As the number of affected children increases, more caregivers are charged with the responsibility of managing their child's food allergy.

OBJECTIVE

To better understand the impact of pediatric food allergy on caregiver quality of life.

METHODS

As part of a larger project examining the knowledge, attitudes, and beliefs of caregivers with food allergic children, the Food Allergy Quality of Life-Parental Burden questionnaire was administered to a large sample of caregivers across the United States from January 1, 2008, to January 31, 2009. Findings were analyzed to describe caregiver quality of life and to examine the impact of the manifestation of food allergy on participant response.

RESULTS

Data were collected from 1,126 caregivers. The impact of food allergy on caregiver quality of life varied widely with 1 exception: caregivers consistently reported being troubled by social limitations resulting from their child's food allergy. Poor quality of life was significantly more likely on a number of survey items among caregivers more knowledgeable about food allergy and among caregivers whose children had been to the emergency department for food allergy in the past year, had multiple food allergies, or were allergic to specific foods.

CONCLUSIONS

Previous research has emphasized the negative impact of food allergy on caregiver quality of life. This study illustrates the diverse experience of caring for a child with food allergy and the importance of considering the manifestation of disease when evaluating parental burden.

Establishing the diagnosis of peanut allergy in children never exposed to peanut or with an uncertain history: a cross-Canada study

The diagnosis of peanut allergy (PA) can be complex especially in children never exposed to peanut or with an uncertain history. The aim of the study is to determine which diagnostic algorithms are used by Canadian allergists in such children. Children 1-17 yrs old never exposed to peanut or with an uncertain history having an allergist-confirmed diagnosis of PA were recruited from the Montreal Children's Hospital (MCH) and allergy advocacy organizations. Data on their clinical history and confirmatory testing were compared to six diagnostic algorithms: I. Skin prick test (SPT) >or=8 mm or specific IgE >or=5 kU/l or positive food challenge (+FC); II. SPT >or=8 or IgE >or=15 or +FC; III. SPT >or=13 or IgE >or=5 or +FC; IV. SPT >or=13 or IgE >or=15 or +FC; V. SPT >or=3 and IgE >or=5 or IgE >or=5 or +FC; VI. SPT >or=3 and IgE >or=15 or IgE >or=15 or +FC. Multivariate logistic regression analysis was used to identify factors associated with the use of each algorithm. Of 497 children recruited, 70% provided full data. The least stringent algorithm, algorithm I, was applied in 81.6% (95% CI, 77-85.6%) of children and the most stringent, algorithm VI, in 42.6% (95% CI, 37.2-48.1%).The factor most associated with the use of all algorithms was diagnosis made at the MCH in those never exposed to peanut. Other factors associated with the use of specific diagnostic algorithms were higher paternal education, longer disease duration, and the presence of hives, asthma, eczema, or other food allergies. Over 18% (95% CI, 14.4-23.0%) of children were diagnosed with PA without fulfilling even the least stringent diagnostic criteria.

The management of the allergic child at school: EAACI/GA2LEN Task Force on the allergic child at school

Allergy affects at least one-quarter of European schoolchildren, it reduces quality of life and may impair school performance; there is a risk of severe reactions and, in rare cases, death. Allergy is a multi-system disorder, and children often have several co-existing diseases, i.e. allergic rhinitis, asthma, eczema and food allergy. Severe food allergy reactions may occur for the first time at school, and overall 20% of food allergy reactions occur in schools. Up to two-thirds of schools have at least one child at risk of anaphylaxis but many are poorly prepared. A cooperative partnership between doctors, community and school nurses, school staff, parents and the child is necessary to ensure allergic children are protected. Schools and doctors should adopt a comprehensive approach to allergy training, ensuring that all staff can prevent, recognize and initiate treatment of allergic reactions.

Time trends in the prevalence of peanut allergy: three cohorts of children from the same geographical location in the UK

BACKGROUND

This article investigated the prevalence of peanut allergy in three cohorts of children born in the same geographical location, Isle of Wight, UK and seeks to determine whether the prevalence of peanut allergy has changed between 1994 and 2004.

METHODS

Three cohorts of children (age 3-4 years) born on the Isle of Wight, were assessed for peanut allergy and the outcomes compared: Cohort A: Born in 1989; reviewed at 4 years of age (n = 2181). Cohort B: Born between 1994 and 1996; reviewed between 3 and 4 years of age (n = 1273). Cohort C: Born between 2001 and 2002; reviewed at 3 years of age (n = 891).

RESULTS

Peanut sensitization increased significantly from 1.3% in Cohort A to 3.3% (P = 0.003) in Cohort B before falling back to 2.0% in Cohort C (P = 0.145). Similarly, clinical peanut allergy increased significantly from 0.5% in Cohort A to 1.4% (P = 0.023) in Cohort B, with a subsequent fall to 1.2% in Cohort C (P = 0.850).

CONCLUSIONS

Our data from three cohorts of 3- to 4-year-old children born in the same geographical area shows that peanut allergy prevalence has changed over time. Peanut sensitization and reported allergy in children born in 1994-1996 increased from 1989 but seems to have stabilized or slightly decreased since the late 1990s, although not significant.

Characteristics of food-allergic patients placing them at risk for a fatal anaphylactic episode

Food allergy is a growing public health and food safety concern. Twelve million Americans-4% of the population-suffer from the disease, and the prevalence is increasing. There is no cure for food allergy; strict avoidance is the only way to prevent a reaction. Food allergy is a major cause of anaphylaxis, a severe, potentially life-threatening allergic reaction that results in an estimated 30,000 emergency department visits and 100 to 150 deaths annually. Factors that place food-allergic patients at greater risk for a fatal anaphylactic episode include asthma; being a teen or young adult; peanut, tree nut, and seafood allergy; not carrying epinephrine; restaurant food; spending time in schools and child care settings; and lack of information from health care providers. Better education of patients and their families about managing their food allergy and high-risk situations can help to prevent future fatalities.

Occupational allergy and asthma among salt water fish processing workers

BACKGROUND

Fish processing is a common economic activity in Southern Africa. The aim of this study was to determine the prevalence and host determinants of allergic symptoms, allergic sensitization, bronchial hyper-responsiveness and asthma among workers processing saltwater fish.

METHODS

A cross-sectional study was conducted on 594 currently employed workers in two processing plants involved in pilchard canning and fishmeal processing. A modified European Community Respiratory Health Survey (ECRHS) questionnaire was used. Skin prick tests (SPT) used extracts of common airborne allergens, fresh fish (pilchard, anchovy, maasbanker, mackerel, red eye) and fishmeal. Spirometry and methacholine challenge tests (MCTs; tidal breathing method) used ATS guidelines.

RESULTS

Work-related ocular-nasal symptoms (26%) were more common than asthma symptoms (16%). The prevalence of atopy was 36%, while 7% were sensitized to fish species and 26% had NSBH (PC(20) < or = 8 mg/ml or > or =12% increase in FEV(1) post-bronchodilator). The prevalence of probable occupational asthma was 1.8% and fish allergic rhino-conjunctivitis 2.6%. Women were more likely to report work-related asthma symptoms (OR = 1.94) and have NSBH (OR = 3.09), while men were more likely to be sensitized to fish (OR = 2.06) and have airway obstruction (OR = 4.17). Atopy (OR = 3.16) and current smoking (OR = 2.37), but not habitual seafood consumption were associated with sensitization to fish.

CONCLUSIONS

Based on comparison with previous published studies, the prevalence of occupational asthma to salt water fish is lower than due to shellfish. The gendered distribution of work and exposures in fish processing operations together with atopy and cigarette smoking are important determinants of occupational allergy and asthma.

Evaluation of efficacy and sedative profiles of H(1) antihistamines by large-scale surveillance using the visual analogue scale (VAS)

BACKGROUND

H(1) antihistamines are widely used as therapeutics for allergic diseases. Sedation is a well-known side effect of H(1) antihistamines and sometimes it is life-threatening for patients. Thus it is important to evaluate the sedative properties of H(1) antihistamines to avoid side effects. For this purpose, histamine H(1) receptor (H1R) occupancy and proportional impairment ratios (PIR) are now being used. However, it is not easy to obtain these parameters. Here, we sought to evaluate the sedative properties of H(1) antihistamines by means of a large-scale surveillance at health insurance pharmacies.

METHODS

The survey was conducted at 37 health insurance pharmacies. The therapeutic efficacy and the degree of sleepiness were quantified through a questionnaire using the visual analog scale (VAS) directly from 1742 patients who received H(1) antihistamines.

RESULTS

The degree of sleepiness caused by the first-generation antihistamines was significantly higher than that of the second-generation antihistamines. The high VAS score in case of efficacy was found in d-chlorpheniramine, olopatadine, and ebastine. Among the mean values of efficacy, all second-generation antihistamines except for loratadine, bepotastine, and mequitazine were significantly higher than that of clemastine. Regarding the degree of sleepiness, clemastine scored the highest VAS score, and significantly lower scores were obtained in all second-generation antihistamines.

CONCLUSIONS

The sedative properties of the H(1) antihistamines obtained from VAS analysis were very similar to those of H1R occupancy from positron emission tomography (PET) studies and PIR from meta-analysis. Our results indicate that large-scale surveillance using VAS might be useful to evaluate the profiles of H(1) antihistamines.

New visions for food allergy: an iPAC summary and future trends

The spectrum of food allergy consists of a variety of different clinical pictures including immunoglobulin (Ig)E, and non-IgE food allergy as well as mixed, IgE and non-IgE disorders. In addition, eosinophilic diseases of the gastrointestinal (GI) tract with occasional IgE-type sensitization are increasingly recognized. As a consequence, the clinical picture of food allergy is pleomorphic and can range from chronic GI symptoms to severe anaphylaxis. The diagnosis of food allergy is mostly hampered by the lack of reliable in vitro tests for non-IgE-mediated diseases, and in most cases relies on a reoccurrence of symptoms upon re-exposure to the antigen; in general during a standardized food challenge. Currently, there is no safe and efficient treatment for food allergy and the treatment relies on avoidance diets. Priorities for research have been identified by iPAC (international Pediatric Allergy and Asthma Consortium) and outlined in this review. They include studies to better identify the pathogenesis of food allergy, including genetic aspects; studies to develop diagnostic and follow-up tests; studies for standardization of food challenges; as well as studies addressing a safe and efficient treatment of food allergy.

Peanut and tree nut allergy in childhood

Peanut and tree nut allergies present multiple challenges in their presentation and management. These challenges have become increasingly relevant in recent years, as these allergies appear to have become more common. An estimated 1-2% of the population in the USA is allergic to peanut or tree nuts. Peanut allergy typically presents with symptoms in one of the first few exposures to peanut. Diagnosis is based on clinical history along with skin prick test, or quantitation of allergen-specific immunoglobulin E (IgE), and oral food challenges when indicated. Once the diagnosis is confirmed, the only current management approach is strict avoidance of the food. This is clearly an imperfect option as it can be difficult to avoid completely peanut and tree nuts and accidental exposures are not uncommon. Only about 20% of those with peanut allergy, and <10% of those with tree nut allergy, are reported to acquire tolerance. Additionally, peanut allergy can recur, with one study finding a recurrence rate of 8%. Peanut and tree nuts are the foods most frequently associated with fatal episodes of anaphylaxis. This is of particular concern in adolescents and young adults, among whom life-threatening and fatal food allergy-related reactions are most common.

The European labelling law for foodstuffs contains life-threatening exemptions for food-allergic consumers

The prevalence of food allergies still continues to rise in western Europe. As the strict avoidance of food allergens represents a major issue in the management of this disease, information for consumers on food labels about allergenic ingredients is crucial. The European labelling law for foodstuffs excludes declarations of the ingredients on individually wrapped foodstuffs with outer packages and products whose largest single surface area falls below 10 cm(2). One potentially avoidable case, with fatal consequences due to this law and the current legal situation, is discussed herein. We suggest evaluating the benefits of a mandatory safety warning (symbol) for major allergenic food ingredients on every foodstuff package, without any exceptions based on the size of the product or the presence of secondary packages.

The prevalence, cost and basis of food allergy across Europe

The development of effective management strategies to optimize the quality of life for allergic patients is currently hampered by a lack of good quality information. Estimates of how many individuals suffer from food allergy and the major foods involved vary widely and inadequacies of in vitro diagnostics make food challenges the only reliable means of diagnosis in many instances. The EuroPrevall project brings together a multidisciplinary partnership to address these issues. Cohorts spanning the main climatic regions of Europe are being developed in infants through a birth cohort, community surveys in school-age children and adults and an outpatient clinic study. Confirmatory double-blind placebo-controlled food challenge diagnosis is being undertaken using foods as they are eaten with titrated doses to allow no-effect and lowest-observable effect levels for allergenic foods to be determined. The cohorts will also facilitate validation of novel in vitro diagnostics through the development of the EuroPrevall Serum Bank. Complementary studies in Ghana, western Siberia, India and China will allow us to gain insights into how different dietary patterns and exposure to microorganisms affect food allergies. New instruments to assess the socioeconomic impact of food allergy are being developed in the project and their application in the clinical cohorts will allow, for the first time, an assessment to be made of the burden this disease places on allergy sufferers and their communities.

Allergic reactions in the community: a questionnaire survey of members of the anaphylaxis campaign

BACKGROUND

Allergic reactions to food are well recognized in both children and adults, but because of their relative infrequency their typical features may not be readily recognized by patients and their medical care givers who are not allergists.

OBJECTIVE

We sought to investigate the circumstances and clinical characteristics of food allergies in adults and children in the community.

METHODS

Self-completed questionnaire responses over a 6-month period from 109 members of the Anaphylaxis Campaign, the major British patient resource group for people who have suffered severe allergic reactions.

RESULTS

One hundred and nine respondents reported 126 reactions during the study period. Seventy-five were children (under 16 years, median age 6 years at the time of reaction). Predictably more boys than girls were reported to have had reactions but more women reported reactions than men (P<0.05). Although the groups were equally aware of their food allergies the children had undergone diagnostic tests more often (P<0.001). Foods were implicated in 112 (89%) of reports. Restaurants were implicated less often (14%) than in other series, probably reflecting British eating habits. Children with asthma reported more severe reactions than those without asthma (P=0.008), although frequency or severity of recent asthma symptoms was not associated with severity of allergic reaction reported. When available, self-injectable adrenaline was used in 35% of severe reactions and 13% of non-severe reactions (P=0.01). A quarter of adults who received one dose of adrenaline also received a second dose.

CONCLUSION

The allergens implicated in this report reflect previous data from similar patient groups in North America. Asthmatic children suffer more severe reactions than non-asthmatic children. It appears that British adults need better access to expert care of their allergies. Even when it is prescribed and available self-injectable adrenaline appears under-used in severe reactions. The incidence of severe but non-fatal allergic reactions in the UK may have been underestimated in the past.

Determination of no-observed-adverse-effect levels and eliciting doses in a representative group of peanut-sensitized children

BACKGROUND

Current labeling practices for allergenic foods like peanut can be inadequate. For future regulatory and industry guidelines, information on no-observed-adverse-effect levels (NOAELs) and eliciting doses (EDs) for allergenic foods is necessary.

OBJECTIVE

To determine NOAEL and ED in a representative group of peanut-sensitized children, relate these data to history and sensitization, and evaluate the outcome of dietary management.

METHODS

From an overall eligible group of 96 peanut-sensitized children, a representative group of 27 was evaluated by questionnaires, skin prick test, determination of specific IgE, and double-blind placebo-controlled food challenge (DBPCFC) with peanut according to the international consensus protocol, with 9 doses ranging from 10 microg to 3 g peanut flour. Dietary management was evaluated over a 12-month period.

RESULTS

Twenty-two children (81%) had a positive DBPCFC. The NOAEL in this group was 1 mg peanut flour, corresponding to 2 mg whole peanut. The ED for subjective symptoms (10 mg to 3 g) was significantly lower than for objective symptoms (100 mg to 3 g; P = .002). Severe reactions occurred only at high doses. EDs were not correlated to previous reactions by history, skin prick test, or specific IgE levels. All patients with a positive DBPCFC were advised to follow a strict diet. During the follow-up period, 10 patients had a less strict diet likely containing traces of peanut. In 3 cases, a mild reaction occurred with food products labeled "may contain peanut."

CONCLUSION

The NOAEL in a representative group of children with peanut allergy was 2 mg. Dietary compliance in half of this group was inadequate.

Allergy-like conditions and health-care contacts among children with exclusion diets at school

AIM

To find out whether children with exclusion diet at school had allergy-like conditions that could explain their food avoidance, the objective of this study was to describe health-care contacts and diagnostic testing among schoolchildren with exclusion diet and compare the magnitude of allergy-like conditions between those children who had vs. had not consulted health-care professionals. Telephone interviews were conducted with the parents of 230 schoolchildren, aged 6-18 years, with certificates for exclusion diets at school.

RESULTS

The majority of the schoolchildren (85%) had consulted health-care professionals for food-related problems, and 68% were doctor-diagnosed as having food hypersensitivity. Those who had consulted health-care professionals specifically for their food-related problems had more complex and severe problems compared with those who had not consulted health-care professionals. Breathing difficulties (27/196) and anaphylaxis (9/196) related to intake of food were reported only for those who had sought health-care professionals (n = 196). Regardless of whether the children had consulted the health-care professionals, their food-related problems were consistent with food hypersensitivity. Schoolchildren avoided food items known to be associated with food hypersensitivity such as tree nuts, fruit, egg, peanut, lactose and fish. Furthermore, 83% of the 230 children also had allergic diseases (i.e. asthma, eczema or hay fever) or were hypersensitive to other substances besides food, and 83% had at least one sibling or parent with hypersensitivity to foods or other substances.

CONCLUSIONS AND IMPLICATIONS FOR THE SCHOOL NURSE

Schoolchildren with food certificates for exclusion diets, based on parents' statements, have food-related and allergy-like problems that may well motivate exclusion diets at school. The school nurses can rely on the parents' information as to what foods their children should avoid, even when doctor diagnoses have not been made or health-care consultations have not been carried out.

Adult food allergy

Adult food allergy is estimated at approximately 3.2% worldwide. The persistence of childhood food allergy is unusual, peanut allergies excepted. Once established in adults, food allergy is rarely cured. Factors favoring the acquisition of allergy could be sensitization to pollens, occupational sensitization by inhalation, drugs (such as tacrolimus), and sudden dietary changes. Severe anaphylaxis and oral allergy syndrome are frequent. The fatality risk is estimated at 1% in severe anaphylaxis. Risk factors for severe anaphylaxis are agents causing increased intestinal permeability, such as alcohol and aspirin. b-blockers, angiotensin-converting enzyme (ACE) inhibitors, and exercise are other factors. Gastrointestinal food allergy remains, to a large extent, undiagnosed in adults. Food allergens are mainly fruit and vegetable, related to pollen sensitizations, or to latex allergy. Wheat flour allergy is increasing. The diagnosis relies on prick skin tests, detection of specific IgEs, and standardized oral challenges. Strict avoidance diets are necessary. Specific immunotherapy to pollens may be efficient for cross-reactive food allergies.