Food-induced anaphylaxis to a known food allergen in children often occurs despite adult supervision

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.

Food allergy-A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review

Following a diagnosis of IgE-mediated food allergy, to secure the best outcome, the patient should receive individualized advice tailored to their specific needs, which considers the type and presentation of the food involved, level of exclusion required, risk of cross-contamination and any variance required for age, ethnicity, financial issues, and lifestyle. Issues such as food labels "may contain" statements, and variation in the threshold of reaction and impact of cofactors should also be considered. Most important is the need to ensure that the diagnosis is robust, especially given the nutritional, psychological, and socioeconomic issues that can affect an individual with a diagnosis of food allergy. Unnecessary exclusion of one or more foods that have not triggered allergic reactions, especially in individuals with allergic comorbidities, can result in severe IgE-mediated reactions on re-exposure. Given that food allergies may change over time, the diagnosis should be reviewed, to determine whether resolution is likely, or new-food triggers are reported. Regular assessment is vital, especially during childhood, to ensure reintroduction occurs at an appropriate time, thus enabling increased diversity of the diet and improvement in the quality of life. For some, an IgE-mediated food allergy may necessitate the life-long exclusion of foods, and for others, a food habitually eaten suddenly triggers an allergic reaction in adult life. People of all ages, ethnicities, and socioeconomic backgrounds deserve individual advice on the management of their food allergy to support a healthy diet and improve quality of life.

Parents' Communication Work in the Management of Food Allergies

The National Academies of Sciences, Engineering, and Medicine (NASEM) has identified food allergies as a critical public health issue that significantly affects quality of life for patients and their families. Despite the crisis-level status of food allergies, especially in children, there are currently no curative treatments. As a result, impacted families must learn how to carry the burden of disease management. Using an expanded application of the concept of communication work, this study features data from interviews with 26 parents of food allergic children and explores how parents navigate the nuances of food allergy maintenance while negotiating and preserving valued relationships and identities through everyday talk. Results revealed that parents used communication to legitimate food allergy, balance potential face-threats with identity and relational goals, and coordinate care with spouses. Due to the lack of therapeutic treatment options, we found that parents utilize communication work, which is both demanding and effortful, as a form of disease management.

Economic burden of food allergy in Canada: Estimating costs and identifying determinants

BACKGROUND

Limited data exist on the economic burden of food allergy (FA).

OBJECTIVE

To assess FA-related direct (healthcare and out-of-pocket) and indirect (lost productivity) costs and their determinants in Canadian children and adults self-reporting FA.

METHODS

FA-individuals self-reporting a convincing history or physician diagnosis were recruited through FA registries, an anaphylaxis registry, and advocacy associations, and electronically surveyed regarding FA-related healthcare use, out-of-pocket expenditures, and time lost from paid and unpaid labor. Direct and indirect costs (2020 Canadian dollars [CAD]) were stratified on severe reaction vs mild, moderate or no reaction, and children vs adults; multivariate regressions assessed the association between costs and sociodemographic and disease characteristics.

RESULTS

Between May 2018 and July 2019, 2692 eligible individuals responded (2189 convincing history and 503 physician diagnosis only); 1020 experienced a severe reaction; 1752 were children. Per FA-individual, annual healthcare, out-of-pocket, and indirect costs were $1267, $2136, and $7950. Those with a severe reaction had higher healthcare and out-of-pocket costs than those with mild, moderate or no reaction. FA-children vs FA-adults had higher healthcare and out-of-pocket costs, and lower indirect costs. Multivariate results showed that lower age, a severe reaction ever, multiple FAs, and fair or poor general health were associated with higher healthcare and out-of-pocket costs. Higher age, lower household education and income, and fair or poor general health were associated with higher indirect costs.

CONCLUSION

The economic burden of FA in Canada is substantial, particularly for those with a severe reaction ever, multiple FAs, and fair or poor general health. It is crucial that those most adversely affected are allocated appropriate resources to support disease management.

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Prevention and management of allergic reactions to food in child care centers and schools: Practice guidelines

Food allergy management in child care centers and schools is a controversial topic, for which evidence-based guidance is needed. Following the Grading of Recommendations Assessment, Development, and Evaluation approach, we conducted systematic literature reviews of the anticipated health effects of selected interventions for managing food allergy in child care centers and schools; we compiled data about the costs, feasibility, acceptability, and effects on health equity of the selected interventions; and we developed the following conditional recommendations: we suggest that child care centers and schools implement allergy training and action plans; we suggest that they use epinephrine (adrenaline) to treat suspected anaphylaxis; we suggest that they stock unassigned epinephrine autoinjectors, instead of requiring students to supply their own personal autoinjectors to be stored on site for designated at-school use; and we suggest that they do not implement site-wide food prohibitions (eg, "nut-free" schools) or allergen-restricted zones (eg, "milk-free" tables), except in the special circumstances identified in this document. The recommendations are labeled "conditional" due to the low quality of available evidence. More research is needed to determine with greater certainty which interventions are likely to be the most beneficial. Policymakers might need to adapt the recommendations to fit local circumstances.

Highlights and recent developments in food and drug allergy, and anaphylaxis in EAACI Journals (2017)

This review highlights research advances and important achievements in food allergy, anaphylaxis, and drug allergy that were published in the Journals of the European Academy of Allergy and Clinical Immunology (EAACI) in 2017. Food allergy and anaphylaxis research have continued to rapidly accelerate, with increasing numbers of outstanding developments in 2017. We saw new studies on the mechanisms, diagnosis, prevention of food allergy, and novel food allergens. Drug hypersensitivity, as well as hereditary angioedema, has been highlighted in the present review as the focus of recent developments. The EAACI owns three journals: Allergy, Pediatric Allergy and Immunology (PAI), and Clinical and Translational Allergy (CTA). One of the major goals of the EAACI is to support health promotion in which prevention of allergy and asthma plays a critical role and to disseminate the knowledge of allergy to all stakeholders including the EAACI junior members. This paper summarizes the achievements of 2017 in anaphylaxis, and food and drug allergy.

Comparing the eating out experiences of consumers seeking to avoid different food allergens

Background

Eating outside the home is challenging for consumers with food allergy (FA) and intolerance (FI) and lack of allergen information provision in eating out venues can lead to unnecessary restrictions. Following European legislation (2014) designed to improve allergen information provision, little is known about differences in information provision experienced by consumers seeking to avoid particular allergens, or how this impacts on their eating out experiences. This study compared the information provision that consumers with FA/FI to different allergens experience when eating out.

Methods

Using mixed methods, participants were recruited from across the UK and took part in self-report surveys or in-depth interviews. Surveys were completed by 232 participants avoiding either gluten (n = 66), nuts (peanuts/tree nuts) (n = 94), or milk (n = 74), and responses were subject to quantitative analyses. Interviews were carried out with 49 participants avoiding either gluten (n = 13), nuts (n = 14), milk (n = 13) or a combination of these allergens (n = 9), and analysed using the framework approach.

Results

Although general improvements in information provision following the legislation were reported, variations in provision between allergen groups led participants seeking to avoid milk to conclude that their dietary needs were less well-understood and seen as less important. These perceptions were reflected in a reluctance to involve eating out venue staff in deliberations about the potential for milk-free meal options.

Conclusions

The provision of visual indicators of the presence of milk and of staff trained in allergen-awareness would improve the eating out experiences of consumers seeking to avoid milk. Medical professions can play a key role in encouraging these patients to pursue their right to make enquiries about allergens in order to avoid accidental milk ingestion when eating out.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6117-y) contains supplementary material, which is available to authorized users.

Food-Induced Anaphylaxis: an Update

PURPOSE OF REVIEW

This review aims to provide an update of recent advances in the epidemiology, clinical features and diagnosis, and management of food-induced anaphylaxis (FIA).

RECENT FINDINGS

Food allergy prevalence and FIA rates continue to rise, but FIA fatalities are stable. Basophil and mast cell activation tests promise more accurate identification of food triggers. Oral, sublingual, and epicutaneous immunotherapy can desensitize a significant portion of subjects. Epinephrine use for FIA remains sub-optimal. As the burden of food allergy continues to increase, it appears that the corresponding increase in research focused on this epidemic is beginning to bear fruit. The stable number of FIA fatalities in the face of an ongoing epidemic indicates lives have already been saved. The emergence of new diagnostic tests and interventional therapies may transform the management of FIA in the coming years.