Food allergy: Mechanisms, diagnosis, and management in children

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Non-Immune-Mediated Reactions

Food may cause an adverse reaction because of the toxic nature of the food particle. The classic example is food poisoning from botulism, in which the toxin interacts with cyclic adenosine monophosphate regulatory protein. The most common cause of acute food-borne disease of chemical etiology is ciguatera poisoning. Ciguatera is caused by tropical fish by eating dinoflagellate algae, causing a variety of symptoms that are primarily gastrointestinal and neurologic.10

The most common adverse food

Immune-Mediated Disorders of the Gastrointestinal Tract

The GI tract confronts the largest burden of external antigens faced by any organ system. Multiple disorders can be identified based on clinical patterns of presentation (e.g., time of onset, type of symptom, persistence, and severity) and immune mechanism (see previous box titled “Immune-Mediated Adverse Reactions Involving the Gastrointestinal Tract”).

Oral Allergy Syndrome

The oral allergy syndrome is more prevalent in adults than in children. Symptoms are restricted essentially to the oropharynx and include rapid

DIAGNOSIS

The reader should refer to Figure 1, Figure 2, Figure 3, which summarize diagnostic strategies for IgE-mediated, T cell-mediated (FPIES), and mixed immunologic (EE) disorders.

History

The patient's history can be a powerful diagnostic tool, especially if the patient and family are objective historians. The family's own perceptions and knowledge often influence history, however. Food allergy clearly is suspected more often than it is found by accurate diagnostic procedures and is confirmed by challenges in fewer than 20% of cases. In general, the history can be more helpful in IgE-mediated disorders because these reactions occur so soon after food ingestion and because

Physical Examination

A complete physical examination is indicated. Special attention should be directed toward uncovering allergic stigmata in any target organ, the patient's general nutritional status, and the markers of any other chronic disease. The examination, together with the general clinical history, helps to reveal concurrent disorders that may influence the clinical picture. For example, patients with asthma and environmental risk factors causing persistent symptoms offer additional historical and

Laboratory Studies

The general history and examination lead to a list of suspected foods, if any, and the likelihood for IgE- or T cell-mediated processes. Immediate hypersensitivity skin tests probe for the presence of food protein-specific IgE. Standard procedure involves the prick skin test. Multiple devices are available for this procedure, but the authors' preference is a bifurcated steel needle because of enhanced sensitivity and specificity. Intradermal skin testing is not used because of increased

Oral Food Challenges

Often, an elimination diet provides diagnostic information and symptomatic relief. If not, it is possible that not all responsible foods have been eliminated (not all detected in diagnostic workup, hidden goods or contaminants present, or sufficient allergen is contained in “hypoallergenic” casein hydrolysate formula in milk-sensitive patients). Elemental diets (e.g., Neocate or EleCare) also may be helpful because they avoid all protein allergens. If the elimination diet is successful, food

GENERAL THERAPEUTIC CONSIDERATIONS

The only proved therapy for food allergy is food elimination, which may require an intensive learning process and work on the patient's and caregiver's parts because of pervasiveness or hidden allergens. Certain situations bear a high risk for adverse reaction, such as eating foods prepared by others in cafeterias or restaurants. Finally, dietary elimination may lead to nutritional deficiency. Therefore, nutritional support services and continued diagnostic procedures to further limit the list

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