Presentation on theme: "Food Allergy: A Teaching Module For The Non-Allergist"— Presentation transcript:
1 Food Allergy: A Teaching Module For The Non-Allergist (Draft Presentation)Multi-Faceted Food Allergy Education ProgramThe slide set is intended to provide primary care and emergency department physicians with an overview of the diagnosis and management of food allergic disorders. Emphasis is placed upon diagnosis and treatment of life-threatening food allergies and toward making the provider aware of patient resources.The slide set was created by Scott Sicherer, M.D. and Suzanne Teuber, M.D. with funding from the United States Department of Agriculture for a grant entitled “Multifacted Food Allergy Education Program.” Revisions were undertaken based upon validation studies. Acknowledgments to Joyce Yu, MD for assisting in those studies. We consider this slide set up to date as of September This slide set is to be considered a teaching tool for health care providers and is not a comprehensive management plan or diagnostic manual. Neither the authors nor the USDA assume any responsibility for errors or adverse outcomes associated with these teaching materials.The following are prime references used for this teaching module:Sampson HA, Munoz-Furlong A, Campbell RL. et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Lieberman P, Kemp SF, Oppenheimer JJ, et al. The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol 2005; 115 (3):SSicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):Chapman JA, Bernstein IL, Lee, RE, Oppenheimer J, Nicklas RA, Portnoy, JM, Sicherer SH, Schuller DE, Spector SL, Khan D, Lang D, Simon RA, Tilles SA, Blessing-Moore J, Wallace D, Teuber SS. Food allergy: a practice parameter. Ann Allergy Asthma Immunol Mar;96(3 Suppl 2):S1-68.Funding provided by the United States Department of Agriculture
2 Learning ObjectivesUnderstand the clinical manifestations of food allergic disordersAppreciate the utility of tests used to diagnose food allergyRecognize and understand the management of food-induced anaphylaxisAppreciate and respond to the educational needs of patients diagnosed with food allergy in regard to avoidance and treatmentFour objectives are emphasized.
3 Perceived versus True Food Allergy About 20% in the general population perceive themselves to have a “food allergy”Food allergy is an adverse immune response to food proteinIgE antibody mediated: sudden allergic reactionsCell-mediated reactions: chronic symptomsMany reasons for adverse reactions to foodsIntolerance (e.g., lactose intolerance)Toxic (e.g., food poisoning)Pharmacologic (e.g., caffeine)Estimated prevalence of food allergy (increasing)6-8% of young children2-4% of adultsNearly one in five individuals avoid food(s) because of a perceived “food allergy.” However, true food allergy, defined as an adverse immune response to food protein, affects 6-8 % of children and 2-4% of adults. The immune response often involves IgE antibodies that detect food proteins, but in some types of food allergy the reactions are mediated by cellular responses rather than humoral (IgE) ones. Allergic reactions to food dyes and preservatives is very uncommon. In addition to food allergy, adverse reactions to foods may occur for reasons including intolerance (a non immune response), toxic and pharmacologic reasons. Spoiled dark meat fish may induce a toxic allergic –type reaction due to release of histamine like compounds.References:Sicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):Sicherer SH. Food Allergy. Lancet;2002;360:Sicherer SH. Sampson HA. Food Allergy J Allergy Clin Immunol, 2006;(in press)Sicherer SH. Muñoz-Furlong A, Sampson HA. Prevalence of Peanut and Tree Nut Allergy in the US determined by a Random Digit Dial Telephone Survey: A Five Year Follow-Up Study. J Allergy Clin Immunol. 2003;112:Sicherer SH, Muñoz-Furlong A, Sampson HA. Prevalence of seafood allergy in the United States determined by a random telephone survey. J Allergy Clin Immunol 2004;114:
4 Life-Threatening Food Allergies Are Associated with Production of IgE Antibodies IgE antibodies circulate in the bloodstream and bind to receptors on basophils and tissue mast cellsBinding of a food protein to the antibodies triggers release of mediators (e.g., histamine) causing symptomsBasis for allergy tests (serum tests for food-specific IgE and allergy prick/puncture skin tests)Sudden allergic reactions that may be immediately life-threatening are typically associated with the production of IgE antibodies. These specific antibodies arm tissue mast cells and blood basophils. When the protein cross links IgE antibodies on the surfaces of these cells, signal transduction results in release of preformed mediators (e.g., histamine) that mediate reactions.Mast cellIgE antibodyHistamineFood ProteinRelease ofHistamineArmed Mast CellActivated Mast Cell
5 Common Causal Foods Common for severe reactions PeanutTree Nuts (e.g., walnut, cashew)Shellfish (e.g., shrimp)Fish (e.g., cod)But, potentially others such as seeds, etc.Common foods causing mild reactions (usually)FruitsVegetablesCommon allergens for children, usually outgrown*MilkEggWheatSoyAny food can potentially trigger a food allergic response. Most (~85%) of the significant food allergies are caused by a rather short list of foods often termed the “major allergens” (milk, egg, peanut, wheat, soy, tree nuts, fish and shellfish). Severe and life threatening food allergies are most typically associated with responses to peanut, nuts from trees, fish and shellfish. Milk, egg, wheat and soy allergies are more common in infants and children and these allergies often abate by late childhood. While not typically severe, allergic reactions to milk, egg, wheat soy and even fruits and vegetables may be severe in some persons. 85% of young children outgrow egg, milk, wheat and soy allergy by age 5 years; though peanut allergy tends to persist, 20% of young children with a peanut allergy will experience resolution of the allergy by age 5 years.References:Sicherer SH, Muñoz-Furlong A, Sampson HA. Prevalence of seafood allergy in the United States determined by a random telephone survey. J Allergy Clin Immunol 2004;114:Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107(1):191-3.Wood RA. The natural history of food allergy. Pediatrics 2003; 111(6 pt 3):*20% of young children“outgrow” a peanut allergyBy school-age
6 Spectrum of Food Allergy IgE-Mediated Cell-mediated(Non-IgE-Mediated)Spectrum of Food AllergySkinUrticaria Atopic Dermatitis Angioedema Dermatitis herpetiformis(papulovesicularrash)RespiratoryAsthmaRhinitisGastrointestinalGI “Anaphylaxis” Eosinophilic Celiac diseaseOral Allergy gastrointestinal Infant syndrome disorders gastrointestinalSystemic disordersAnaphylaxisFood-associated, exercise-induced anaphylaxisThe spectrum of food allergic disorders includes sudden reactions that are typically associated with food-specific IgE antibodies, and chronic/indolent disease that may be cell-mediated or partly associated with IgE to the causal foods. GI “anaphylaxis” refers to uncommon isolated immediate gastrointestinal reactions. Oral allergy syndrome occurs in persons who are pollen-allergic and experience mild (usually) symptoms of oral itch or mild lip swelling to raw fruits or vegetables that contain proteins that are homologous to those in the pollens. Heating/cooking typically denatures the proteins and so these symptoms are not typically associated with cooked fruits or vegetables. Food-associated, exercise induced anaphylaxis refers to a syndrome where eating a particular food (sometimes any food) before exercise results in a severe allergic reaction. Wheat and celery are typical associated triggers. This teaching module will not emphasize the diagnosis/management of the more indolent disorders, such as atopic dermatitis, eosinophilic gastrointestinal diseases, Celiac disease (which can be associated with dermatitis herpetiformis) and gastrointestinal disorders of infancy. One such disorder, food protein induced enterocolitis syndrome, is characterized by severe vomiting, diarrhea, hypotension and methemoglobinemia and is a severe, but not IgE antibody associated, form of food allergy.Reference:Sicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):
7 Diagnosis May Be a Challenging Eosinophilic esophagitisChronic symptomsGastrointestinal, skin or respiratoryOnly sometimes related to food allergyNo history of a “trigger” foodMultiple possible triggersMany foods in the dietDefinitive outcomes neededTo know what to eat/avoidMasqueradersMany illnesses can appear to be food allergy“Imperfect” testsDetection of IgE to a food (e.g., by serum or skin tests) reveals “sensitization” which is not always a proof of clinical reactionApproximate sensitivity is 50-80%, specificity 90-95% (false positives and false negatives)Atopic dermatitisNeurologically-mediatedvasodilatation) causedby tart foods(auriculotemporalsyndrome)The diagnosis of chronic disorders caused by food allergy is beyond the scope of this tutorial, but is complicated by the lack of simple diagnostic tests. In regards to IgE antibody associated allergic reactions, the clinician must determine, by the history, the likelihood of a food allergy (as compared to another disorder) and the potential causal food. Tests for food-specific IgE antibodies are very sensitive, but clinical history must be considered to improve the specificity of the test. However, many persons may test positive to foods that are not causing them any disease, making the history a very important aspect of the evaluation and emphasizing that the tests are not appropriate for screening.Reference:Sicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):Positive skin test
8 Food Allergy Evaluation* HistoryDetails of diet, possible triggers, alternative diagnosesPhysicalTo exclude other causesTestingTests for IgE to suspected trigger(s)Skin prick tests by an allergistSerum tests widely available (not affected by anti-histamines)May require diet elimination/physician supervised oral food challengesThe history may reveal that a food allergic reaction was likely (typical symptoms occurring promptly following ingestion of a trigger food) and may disclose possible triggers. Skin prick tests are typically performed by allergists. Otherwise, serum tests, often colloquially termed “RAST tests” can be used to detect serum food-specific IgE antibodies. Unlike skin tests, antihistamines do not affect the serum IgE test results. A positive IgE test to a suspected food may confirm the allergy. However, in some circumstances, dietary elimination and physician-supervised oral food challenge may be needed to confirm a diagnosis if the laboratory tests and history are not conclusive. Such testing is usually pursued by an allergist.Reference:Sicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):*Additional procedures may be needed
9 Tests for Food-Specific IgE Amount of food-specific IgE reflected by serum level or skin test sizeIncreasing “level” roughly reflects increasing risk of a reaction“Level” does not correlate well with “severity”Modest sensitivity and specificitymakes tests poor for “screening”clinical history is very importantreaction could occur despite “negative” testHere are summarized a few important points about allergy tests. Depending upon the serum test ordered, various units may be reported such as kilo-units, counts, or classes. In general, the greater the test level, the more likely the result may reflect a true allergy. Allergy skin test size and level on serum tests generally correlate well. However, the degree of positive allergy test result does not reflect severity of an allergy. A person with a “low level” result could have a more severe reaction than a person with a higher number on the test. Various factors such as cross-reactive proteins, digestion, immune responses and many other factors determine whether a true allergy exists and so many people could test positive to a food they will tolerate. Therefore, the clinical history is vital for interpreting tests appropriately. A positive test does not always indicate a clinical reaction and a negative test is sometimes found in persons who develop a reaction upon ingestion. Interpretation of the tests must therefore consider likelihood of allergy (prior probability) determined by a clinical history.
10 Food AnaphylaxisAnaphylaxis is a serious allergic reaction that is rapid in onset and may cause deathFood is the most common cause of community anaphylaxisAnaphylaxis may be biphasicQuiescent period after initial symptoms and recurrence of symptoms in the subsequent hoursAnaphylaxis usually occurs rapidly and can be potentially fatal. It can be caused by foods, insect venom, drugs, and other triggers, but food allergy is the most common cause for anaphylaxis outside of a hospital setting. Sometimes, initial symptoms abate and recur a few hours later (biphasic response), or persist for many hours.References:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Lieberman P, Kemp SF, Oppenheimer JJ, et al, The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol 2005; 115 (3):SBock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107(1):191-3.Sampson HA, Mendelson LM, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med 1992; 327:380-4.
11 Food Anaphylaxis Risk factors for fatal, food-induced anaphylaxis Major risk factor: delayed use of epinephrineHigh risk groups: teenagers/young adultsHigh risk co-morbidity: asthmaConfusing physical symptom: urticaria may be absentFatalities have been associated with the delayed use of epinephrine and certain high risk groups such as teenagers and individuals with asthma. Though one may expect to see urticaria during an allergic reaction, it is possible to have anaphylaxis without urticaria.References:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Lieberman P, Kemp SF, Oppenheimer JJ, et al, The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol 2005; 115 (3):SBock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107(1):191-3.Sampson HA, Mendelson LM, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med 1992; 327:380-4.
12 Criteria for Anaphylaxis (anaphylaxis is likely) 1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g., generalized hives, pruritus or flushing, swollen lips/tongue/uvula)AND AT LEAST ONE OF THE FOLLOWINGa. Respiratory compromise (e.g., dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow (PEF), hypoxemia)b. Reduced blood pressure (BP) or associated symptoms of end-organ dysfunction (e.g.,hypotonia [collapse], syncope, incontinence)An expert panel convened by the National Institutes of Health identified 3 criteria that, when fulfilled, has a high likelihood to represent anaphylaxis.Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol Feb 2006;117:391-7.NIH Panel report 2006
13 Criteria for Anaphylaxis (anaphylaxis is likely) 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):a. Involvement of the skin/mucosal tissue (e.g., generalized hives, itch/flush, swollen lips/tongue/uvula)b. Respiratory compromise (e.g., dyspnea, wheeze/bronchospasm, stridor, reduced PEF, hypoxemia)c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence)d. Persistent GI symptoms (e.g., crampy abdominal pain, vomiting)Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol Feb 2006;117:391-7.
14 Criteria for Anaphylaxis (anaphylaxis is likely) 3. Reduced blood pressure following exposure to known allergen for that patient (minutes to several hours):a. Infants and Children: low systolic BP (age-specific) or >30% drop in systolic BP*b. Adults: systolic BP <90 mmHg or >30% drop from that person’s baseline* Low systolic BP for children is defined as <70 mmHg from 1 month to 1 year; less than (70 mmHg + [2 x age]) from 1-10 years; and <90 mmHg from age years.Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol Feb 2006;117:391-7.
15 Treatment of Anaphylaxis: Epinephrine Dose: 0.01 mg/kg (max 0.5 mg)0.01 cc/kg of 1:1,000 concentrationRoute: intramuscularHigher and quicker peak serum levels compared to subcutaneousConsider intravenous for severe hypotension/arrestMonitor, titrate, higher risk of dysrhythmiasLocation: anterior, lateral thigh (vastus lateralis)Higher and quicker peak serum levels compared to deltoidFrequency: ~5-15 minutes (adjusted clinically)Epinephrine is the drug of choice for anaphylaxis. Intramuscular injection into the anterior-lateral thigh has been noted to provide higher and quicker peak levels although the subcutaneous route has been used successfully as well. Intravenous epinephrine may be indicated for severe hypotension or shock, but carries a higher risk for cardiac dysrythmias.Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: Intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001;108(5 part 1)871-3.
16 Treatment of Anaphylaxis: Typical Treatments Antihistamine (H1 and H2 Blockers)Slower in onset than epinephrine (e.g. 30 minutes)Second-line therapyLittle effect on blood pressureHelpful for urticaria, angioedema, pruritusAddition of H2 blockade (may improve treatment of cutaneous manifestations)Adrenergic agentsInhaled beta-2 agonists may be useful for bronchospasm refractory to epinephrineCorticosteroidsMay prevent protracted/biphasic course but not provenIn addition to epinephrine, standard adjunct therapies include antihistamines such as H1 and H2 blockers, beta-2 adrenergic agents, and corticosteroids. However, it should be noted that most of these adjunct medications have not been prospectively studied in the setting of anaphylaxis. Antihistamines have a slow onset of action and do not affect blood pressure. Therefore, antihistamines are not first line therapy for anaphylaxis. H2 blockers may add efficacy to H1 blockers, but the primary effect is upon urticaria and angioedema. Due to their slow onset of action, corticosteroids are also not first line therapy for anaphylaxis but their use is presumed to reduce the likelihood of biphasic/protracted response (equivalent 1-2 mg/kg /dose methylprednisolone every 6 hours).Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol Feb 2006;117:391-7.
17 Treatment of Anaphylaxis: Advanced Treatment Options OxygenFluid resuscitationVasopressorsGlucagonPresumptive for epinephrine recalcitrant/beta-blockadePhysical position during anaphylactic shock (unless precluded by vomiting or respiratory distress)Recumbent with legs raisedCase reports of death when raised to upright position (“empty ventricle”)Further treatment options include oxygen, fluid boluses, vasopressors, and glucagon. Glucagon may improve the efficacy of epinephrine in persons with recalcitrant anaphylaxis on beta-blocker therapy. Persons experiencing anaphylactic shock should be positioned lying down with raised extremities to promote an increase in intravascular volume centrally to vital organs, if safe and possible to do so. Deaths have been reported when a person in anaphylactic shock was raised to an upright position, presumably due to loss of circulatory volume to the lower extremities.Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol Feb 2006;117:391-7.Pumphrey RSH. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003;112(2):451-2.
18 Observation Following Anaphylaxis: ≥ 4 hours Symptoms may recur ( studies vary, 1-20% of episodes)Biphasic reaction may be more severeOnset varies (studies vary, 1-72 hours)Recommended observation 4-6 hours for most patientsLonger for more severe symptomsMore caution for patients with asthmaStudies show a wide range of time to onset of biphasic reactions. Experts suggest a 4 to 6 hour observation period in most cases, but a longer period if initial symptoms were more severe.Reference:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.
19 Aftercare/Food Allergy Care Avoidance/dietary eliminationAt home/Manufactured productsRestaurants/vacation/travelSchoolUnexpected exposuresTreatment of a reactionEmergency plansSelf-administered epinephrineMedical identification jewelryOnce a diagnosis of anaphylaxis is made, advice for dietary avoidance and information about emergency treatment must be provided to patients. Avoidance will be reviewed in subsequent slides and includes meals taken in and outside of the home and avoidance of unexpected exposures in cosmetics or cross contactReference:Sicherer SH, Teuber SS. Academy Practice Paper: Current approach to the diagnosis and management of adverse reactions to foods. J Allergy Clin Immunol 2004;114(5):
20 Dietary Elimination Hidden ingredients (peanut in sauces or egg rolls) Must educate patients to ask questions in restaurantsLabeling issues (changes, errors)Must educate patient to read label each timeCross contamination (shared equipment)Seeking assistanceRegistered dietitian:(Food Allergy & Anaphylaxis Network: ( )Center for Food Safety and Applied Nutrition: (Avoidance of a food allergen is often difficult and requires extensive patient education. Different problems and pitfalls may arise in various circumstances where meals are acquired. A small amount of ingested food allergen can sometimes trigger an allergic reaction for sensitive individuals. Therefore, trace amounts of allergen that may enter food in cross contact during preparation may become important. Patients must be educated about avoidance issues for purchasing manufactured products and for food obtained in restaurants and elsewhere. Food labels must be read each time because ingredients may change, and patients should be taught the limitations of labels (next slide). Persons on restricted diets may need nutritional counseling and supplementation to avoid nutritional deficits. The resources listed provide information on these topics.
21 What the law addresses: Food Allergen Labeling and Consumer Protection Act (Effective Jan 2006)What the law addresses:Must disclose “major food allergens” in plain English wordsMajor food allergens: milk, egg, wheat, soy, peanut, tree nuts, fish, Crustacean shellfishMust name specific tree nut, fish or shellfish (e.g. cashew, tuna, shrimp)May list scientific name (e.g. casein) but if English word equivalent also used (e.g. milk)Legislation requires that “major allergens” be listed on manufactured products either in the “Contains” list or as a parenthetical inclusion. However, it is important to have patients read the label carefully each time they purchase products because ingredients may change. Specific nuts, fish, or shellfish must be listed and companies may continue to use scientific terms as long as the equivalent plain English word is listed.
22 What the law does not address: Food Allergen Labeling and Consumer Protection Act (Effective Jan 2006)What the law does not address:Allergens not considered “major” (i.e. sesame or garlic) may not be identifiedMay be hidden using terms such as “spices” or “natural flavor”Does not apply to non-crustacean shellfish (i.e. clam, squid)“May contain” provisional labeling is voluntaryAllergens that are not listed among the “major” allergens may not be disclosed, so patients may need to call manufacturers to determine certain ingredients when ambiguous terms (e.g., spices) are used for allergens that are not “major allergens.” In addition, labels may indicate a “chance” of allergen contamination. An important resource is The Center for Food Safety and Applied Nutrition ( This Division of the US Food and Drug Association assists with matters of public health and policy regarding food safety, including allergy. Information about labeling and other food allergy issues are posted on this site. There are also links for reporting problems with foods (for example undeclared allergen) through
23 Restaurants Indicate ALLERGY to staff Could otherwise mistake for food “preference”Careful line of communication for food preparationAvoid buffet, sauces, high risk restaurants (e.g., Asian restaurant with peanut allergy/ seafood restaurant with seafood allergy)Avoid cross-contact with allergensConsider “Chef Cards”Allergic reactions may occur in restaurants for a variety of reasons. Shared utensils or equipment (fryers, pans) may result in cross contact of food with an allergen. It is important for patrons and restaurant staff to maintain a clear line of communication to ensure a safe meal is obtained. A “Chef Card” disclosing the allergy may be helpful. Patients should disclose that they have an allergy, not just a distaste for a food.Resource:The Food Allergy & Anaphylaxis Network ( )From:
24 Strategies for Food Allergy in School: Avoidance Increased supervision during meals, snacksNo sharing (food, containers, utensils)Clean tables, toys, hands (younger children)Substitutions: meals, cooking, crafts, scienceIngredient labels for foods brought inEducation of staffDon’t miss the bus: no food parties, ensure communication/supervisionSchool is another common location for food-allergic reactions. A variety of strategies have been recommended to reduce the risk of reactions. A few are listed here. Further resources are shown on the following slides.References:Sicherer SH, Furlong TJ, DeSimone J, Sampson SH. Peanut allergic reactions in schools. J Pediatr 2001;138:56-5.Nowak-Wegrzyn A, Conover-Walker MK, Wood RA. Food-allergic reactions in schools and preschools. Arch Pediatr Adolesc Med. 2001;155(7):790-5.The American Academy of Allergy, Asthma and Immunology. Board of Directors. Anaphylaxis in schools and other child care settings. J allergy Clin Immunol 1998;102:
25 Strategies for Anaphylaxis in School: Treatment Physician-directed protocolsReview of protocols, assignment of rolesMedications readily available (not locked)Education and review:signs of reactiontechnique of medication administrationbasic first aidnotification of emergency medical system (911)A plan must be in place to ensure that the school is able to respond appropriately to an anaphylactic reaction
26 Resources The Food Allergy & Anaphylaxis Network www.foodallergy.org The Food Allergy & Anaphylaxis Network is a lay organization that provides a number of educational programs for schools and families. “FAAN” is a major resource for individuals and families with food allergies. The organization has an internationally recognized medical advisory board that oversees its materials. FAAN provides parent educational conferences, educational books and videos for parents covering essentially every topic in managing food allergy, comprehensive programs for preschools, schools and camps, books for children and teens, research updates and much more. FAAN is also active in education, research and policy regarding food allergy. The site is an excellent resource to stay “up to date” on research and policies regarding food allergy and a newsletter is offered as well. There is also a specific newsletter and website for children and teens.
27 Recommendations for School Several organizations have endorsed a list of recommendations regarding food allergy safety for schools. These recommendations are directed to the school, parents and students.Available at :
28 Unusual/Casual Exposures Kissing (passionate)CosmeticsMedications/vaccines (read labels/inserts)Airborne (usually when cooking resulting in fumes from food, such as eggs, seafood, milk)In addition to ingestion of an allergen, patients should be instructed about addition ways that exposure may result in allergic reactions. However, anaphylaxis is much more likely to be the result of ingestion exposures (unless kissing is passionate).References:Hallett R, Haapanen LA, Teuber SS. Food allergies and kissing. N Engl J Med 2002;346 (23):Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact to peanut butter in peanut-allergic children. J Allergy Clin Immunol 2003;112:
29 Prescription of Self-Injectable Epinephrine IndicationDefinite: For previous anaphylaxisOther: Perceived high riskExamples: peanut/nut/seafood allergy and asthma, reaction to trace amounts, remote locationsDose of self-injectable epinephrineAvailable as 0.15 mg (package insert lbs)Available as 0.30 mg (package insert > 66 lbs)Physician discretion (e.g., switch to 0.3 mg at 55 lbs to avoid under-dosing)Prescription of 2 dosesThough prescription of self-injectable epinephrine is clearly indicated for a person who has experienced anaphylaxis to a trigger they may encounter in the community, there are other potential indications that are more dependant upon specific circumstances. A physician/patient may discuss the utility of having self-injectable epinephrine available for individuals who are at increased risk for anaphylaxis. The package insert indicates dosing at particular weight intervals, but experts have advised that dosing may vary as clinically indicated to avoid significant under-dosing. In the event that more than one dose is needed while the victim is not under medical care, availability of more than one self-injected dose has been advised.References:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Sicherer SH. Simons FER. Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community. J Allergy Clin Immunol 2005;115:
30 Treatment Plan: Use of Self-Injectable Epinephrine Training on self-injector useErrors in activating are common, must reviewTrainers available (DVDs, tapes and websites with instructions from manufacturersTraining on when to injectFor anaphylaxis as defined earlierConsider for fewer symptoms depending upon history/circumstancesExamples: previous severe anaphylaxis and current certain ingestion despite no symptoms, mild symptoms but remote to medical careSeek advanced careActivate emergency services (e.g., 911)It is important to review the technique and indications for use of self-injectable epinephrine. The advice may vary according to the patients individual circumstances. Fatalities have occurred in association with delays in injecting epinephrine, so erring on the side of caution, that is, to inject epinephrine promptly in the event of likely anaphylaxis, is suggested. It is important to review the technique of administration and remind patients about proper storage (not refrigerated, not in direct heat) and to renew prescriptions.References:Sampson HA, Munoz-Furlong A, Campbell RL. Et al. The second symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2006;117:391-7.Sicherer SH. Simons FER. Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community. J Allergy Clin Immunol 2005;115:The American Academy of Allergy, Asthma and Immunology. Board of Directors. Anaphylaxis in schools and other child care settings. J Allergy Clin Immunol 1998;102:
31 Emergency Action Plan/Identification Jewelry Written materials are available to assist in providing a written emergency action plan to patients. Medical identification jewelry is suggested. In the event of anaphylaxis, emergency services (e.g., calling 911) should be activated.From
32 Epinephrine Device Demonstration EpipenTwinjectClick on the device above for which you would like to view a video demonstration
33 Allergy ReferralPersons on limited diet for perceived adverse reactionsPersons with diagnosed food allergyPersons with allergic symptoms in association with food exposuresBecause diagnosis may require advanced testing, and instructions on avoidance and treatment may be complex, referral to a Board-Certified, or equivalent, allergist is suggested. The professional organizations listed have search engines to locate Board-Certified allergists by zip code.The American Academy of Allergy, Asthma and Immunology:The American College of Allergy, Asthma and Immunology:
34 EXAMPLESThe following case examples will illustrate several of major points made in this learning module.
35 Sarah A) Advise to avoid all tree nuts B) Advise to avoid cashew Age 37Ate a cashew cookie and developed anaphylaxis treated in the emergency departmentHistory indicates she typically tolerates cashews, walnuts, almond, peanut, pecan, pistachioWhich is the most appropriate course of action?A) Advise to avoid all tree nutsB) Advise to avoid cashewC) Perform allergy tests to cashewD) Determine the ingredients of the cookie
36 Diagnosis Requires Careful History The cookie package indicated that Brazil nuts were an ingredientSarah had been eating cashews but never frequently ate Brazil nutsAllergy tests were positive to Brazil nut and negative to cashewInstructions could include avoidance of all nut products (may have Brazil) or to continue ingestion of tolerated nuts when certain that Brazil nut is not includedLearning Objective: The first step toward a proper diagnosis is a careful medical history. Sarah usually tolerated a variety of tree nuts, including the one initially mentioned as an ingredient in the cookie. Having additional information about the cookie ingredients allowed for more directed testing.
37 Ronald 35 year old with peanut allergy Ate a cookie and has a few hives around the mouth, no other symptomsWhich of the following actions is most appropriate?A) Inject epinephrine nowB) Inject epinephrine if symptoms progress
38 The Answer Could Depend Upon The Clinical History Has had 6 lifetime accidental peanut ingestionsAll reactions resulted in hivesNo history of asthmaCould monitor and inject if progresses/inject if uncertainHISTORY #26 lifetime peanut ingestions5 with breathing difficulty2 required respirator support/ionotropes5 required epinephrineOne resulted in hives and vomitingShould inject epinephrineLearning objective: The history is an important component to an emergency action plan. Erring on the side of caution and injecting epinephrine in the community setting is advisable.
39 Jim 3 year old Soy allergic Eating hot dog at school picnic (“all beef”)Teacher sees he is thrashing aroundNot breathing, turning blueTeacher has his Self-injectable with herWhat should she do?
40 Masquerader of Anaphylaxis ChokingPanic attackMyocardial infarctionMust assess historyJim was likely choking-Heimlich maneuverMay err on side of administering epinephrine if not certainLearning Objective: Various illnesses may appear similar to anaphylaxis. Recognizing the circumstances of a reaction may aid in proper diagnosis.
41 Stephanie 16 years old, has asthma Sesame allergy (known) Ate a bagel with no visible sesameHas no hives, develops repetitive coughing, hoarse throat, trouble swallowingWhat treatment is most appropriate?A) AntihistamineB) Injected epinephrineC) Asthma inhalerD) Heimlich maneuver
42 Anaphylaxis May Occur Without Hives Inject EpinephrineLearning Objective: Fatalities have been documented for anaphylaxis that occurs without urticaria.
43 Billy 3 years old, asthma Ate friend’s snack Within minutes: Hives, wheezingIN ER: given epinephrine, antihistamineIn ER 45 minutes after ingestion, no more symptomsDischarged home by ERWhat suggestions might you have before he leaves the ER?
44 Follow-Up Care For Food Anaphylaxis Query for possible trigger/suggest avoidanceRefer for/perform diagnostic testingPrescribe/teach self-injectable epinephrine/emergency planMonitor additional time (4-6 hours) to ensure no biphasic/protracted reactionLearning Objective: Anaphylaxis may follow a biphasic course so additional observation is needed. Review of possible triggers and prescription of an action plan is needed (pending more definitive evaluations).
45 Food Allergy and Anaphylaxis Summary Diagnosis requires careful history, testingconsider allergy referralInstruct patients on the signs of an allergic reaction/anaphylaxisInstruct patient on nuances of allergen avoidance dietPackaged goods, restaurants, school, etc.Treatment of life-threatening allergy requires instruction about recognition and management of anaphylaxisEpinephrine is the drug of choice for treatment of anaphylaxis and should be injected promptlyEmergency plans in writingMedical identification jewelryActivation of emergency services (911)
46 Web Resources Food Allergy and Anaphylaxis Network Epipen product websiteTwinject product websiteMedicalert products and services
47 Web Resources Center for Food Safety and Applied Nutrition US Food and Drug Administration MedwatchAmerican Dietetic AssociationAmerican Academy of Allergy, Asthma, and ImmunologyAmerican College of Allergy, Asthma, and Immunology