Food Allergy Diagnosis, Management & Considerations for College Campuses. S. Shahzad Mustafa, MD, FAAAAI
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1 Food Allergy Diagnosis, Management & Considerations for College Campuses S. Shahzad Mustafa, MD, FAAAAI
2 Disclosures Speaker s bureau Genentech, Teva Consultant Genentech, Teva
3 Outline Definitions Diagnosis Management Considerations for college campuses
4 James Daly - Author You cannot be distracted by the noise of misinformation.
5 Definition of a Food Allergy An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a specific food. Boyce. JACI 2010; 126: 1105.
6 Allergy Versus Intolerance Allergy Requires sensitization Validated diagnostic testing Reproducible reactions Dose independent Caused by an individual allergen Cannot block with pre-treatment Desensitization protocols Can lead to death Intolerance Can occur in absence of sensitization Minimal validated diagnostic testing Reactions can occur inconsistently Frequently dose dependent Can be caused by a class effect Validated pre-treatment regimens Desensitization not possible Typically very little mortality
7 Prevalence Food allergy affects 3-6% of children and ~3% of adults in the United States Self reported prevalence ranges from 20-35% Over-diagnosis by physicians as high as 80% Rona. JACI 2007; 120: 638.
8 Over-Diagnosis of Food Allergy Fleischer. J Peds 2011; 158(4): 578.
9 Quality of Life Associated with Food Allergy 70% reported significant effects on social events 60% reported significant effects on meal preparation 40% reported a significant increase in overall stress levels 34% reported an effect on school attendance 10% chose to home school their children Bollinger. Ann All Asthma Imunol : 415. Springston. Ann All Asthma Immunol : 287.
10 Diagnosis Oral Food Challenge
11 Diagnosis - History Common complaints NOT suggestive of an IgE mediated mechanism Isolated rhinitis Isolated cough/asthma Chronic abdominal discomfort Isolated reflux/heartburn Chronic urticaria Fatigue Reactions occur inconsistently Reactions occur only with larger doses Ongoing mild to moderate atopic dermatitis/eczema
12 Food Allergy & Atopic Dermatitis Boyce. JACI 2010; 126: 1105.
13 Common Food Allergens Pediatrics Food % Cow s milk 2.5 Egg white 1.5 Peanut 1.0 Tree nuts 0.5 Wheat 0.4 Soy 0.4 Shellfish 0.1 Finned fish 0.1 Sesame 0.1* Adults Food % Peanut 0.6 Tree nuts 0.6 Shellfish 2.0 Finned fish 0.4 Sesame 0.1* Boyce. JACI 2010; 126: 1105.
14 Diagnostic Tools Skin prick testing and specific IgE testing (RAST, ImmunoCAP, etc) indicate the presence of IgE antibody Skin prick testing and specific IgE testing do NOT prove clinical reactivity Food allergy requires the presence of IgE antibody AND clinical reactivity Upwards of 50-60% of individuals have presence of IgE in the absence of clinical reactivity Celik-Bilgli. Clin Exp All 2005; 35(3): 268.
15 Skin Prick Testing A negative skin test makes allergy very unlikely Less than 5% The likelihood of a true allergy increases with the size of the reactions > 8 mm wheal = > 95% likelihood of allergy Sampson. JACI 2001; 107: 891., Image from WebMD.com,
16 Specific IgE Testing Sampson. JACI 2001; 107: 891.
17 Unproven Diagnostic Testing Intradermal skin testing Atopy patch testing Food IgG or IgG 4 Basophil activation testing Lymphocyte stimulation testing Applied kinesiology Hair analysis Electrodermal testing Cytotoxic tests Ordering food panels of specific IgE testing is not recommended
18 Diagnosis Oral Food Challenge
19 Oral Food Challenges Performed to confirm or refute IgE mediated food allergy or to evaluate resolution of IgE mediated food allergy Skin prick tests commonly remains reactive despite resolution of allergy Van Der Velde. JACI 2012; 130(5): 1136.
20 Safety of Oral Food Challenges Jaffe Food Allergy Institute, Patients aged 8 months 21 years of age Total Challenges 701 Failed challenges 132 (18.8%) Reactions limited to skin symptoms 75 (10.7%) Reactions requiring epinephrine 12 (1.7%) Reactions requiring 2+ doses of epinephrine 1 (0.14%) Reactions requiring treatment in ED 1 (0.14%) Lieberman J. JACI 2011; 128(5); 1120.
21 Food Pollen Syndrome Presents with oropharyngeal itching and discomfort typically with fresh fruits and vegetables in individuals allergic to environmental allergens
22 Food Pollen Syndrome Mechanism is local IgE production Minimal if any risk of anaphylaxis Clinical diagnosis Management Avoid culprit food Continue to consume culprit food Pre-treat with antihistamine Cook/heat culprit food Allergen immunotherapy to environmental allergens
23 Special Considerations Cow s milk allergy Roughly 70% will tolerate baked milk products Alternatives include soy milk, coconut milk, almond milk, rice milk Cannot safely consume goat s milk Egg allergy Roughly 70% will tolerate baked egg products Safe to administer influenza and MMR vaccines Shellfish and finned fish allergy Safe to receive contrast for radiographic studies Systemic reactions with airborne exposure have been reported
24 Special Considerations (cont d) Soy allergy Safe to consume soy lecithin Tree nut allergy Nearly all will tolerate coconut No cross reactivity with seeds Reasonable to avoid certain tree nuts but consume others Peanut allergy 95%+ will tolerate other legumes Nearly all will tolerate highly refined peanut oil Minimal if any risk with airborne exposure
25 Airborne Peanut Allergen Participants consumed peanuts to simulate various conditions Cafeteria setting Sporting event Commercial airliner Participants measured airborne protein via personal air monitors during the eating sessions with room ventilation turned off Perry. JACI 2004; 113(5): 973.
26 Rick of Airborne & Contact Exposure to Peanut Simonte. JACI 2003; 112(1): 180.
27 Precautionary Labeling Hefle. JACI 2007; 120(1): 171.
28 Precautionary Labeling Percentage of Products with Detectable Allergen Hefle. JACI 2007; 120(1): 171.
29 Food Allergy Guidelines Boyce. JACI 2010; 126(6): S1.
30 Mortality Associated with Food Allergy Umasunthar. Clin Exp All 2013; 43: 1333.
31 Management Strict food avoidance Ensure nutritional needs are being met Minimize risk of reaction while maintaining adequate quality of life Be aware of emergency action plan Carry epinephrine at all times Periodically reevaluate for tolerance
32 Points to Consider Unifying factors in nearly all deaths from food allergy Peanut and/or tree nut allergy Sub-optimally controlled asthma Delayed or no administration of epinephrine Previous reactions do NOT predict future reactions No diagnostic tools to predict the severity of reactions Adolescents and college-aged students at higher risk of reactions due to risk-taking behavior
33 College Survey Greenhawt. JACI 2009; 124: 323.
34 Management in School and Higher Education
35 CDC Guidelines A positive psychosocial climate coupled with food allergy education and awareness for all children, families, and staff members can help remove feelings of anxiety and alienation among children with food allergies.
36 Communication Student/Patient Primary Care Physician Parents Allergist Campus Staff
37 Consensus Best Practices for Campus Collaborative, campus-wide approach Transparent and flexible process capable of meeting student needs without being burdensome For student and campus staff Comprehensive food allergy policy Emergency response plan Emergency response training for staff Confidentiality
38 Pilot Guidelines for Higher Education
39 Education of School Personnel Research from Houston Independent School District 62 school nurses responsible for ~61,000 students Compared school data from 2010 and 2012 Intervention: single educational session on food allergy provide to all personnel in 2011 Results Decreased frequency of reactions Improved availability of epi devices Epi device/allergic child ratio = in 2010, 0.77 in 2012 Conclusion: a single education session for school personnel was highly successful in improving the management of food allergies in the school setting Houston Independent School District Experience.
40 Example Policy Adapted from policy statement at Siena College.
41 Summary Although food allergies have increased in prevalence, they are often misdiagnosed, and this has serious implications on quality of life Management is based on food avoidance and appropriate treatment of accidental reactions with epinephrine Management must account for unique properties of individual food allergens Management on campus should be based upon risk assessment, communication, education, and cooperation
42 Thank You
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