Multiple Food Allergies Research Articles

Reactions from Single and Multiple food allergies: Participant Experiences from the FARE (Food Allergy Research) patient registry

Food Allergy (FA) patients are clinically heterogeneous and have unique experiences. We collected information to describe experiences with food allergen reactions between individuals with a single food allergy (SFA) and those with multiple food allergies (MFA).

Erythroderma in a neonate

Erythroderma in a neonate

The Challenges of Managing Multiple Food Allergies and Consequent Food Aversions

The Challenges of Managing Multiple Food Allergies and Consequent Food Aversions

Associations of Food Allergy-Related Dietary Knowledge, Attitudes, and Behaviors Among Caregivers of Black and White Children With Food Allergy

BackgroundThe increasing prevalence of pediatric food allergy (FA) in the United States has disproportionately affected non-Hispanic Black youth. However, racial and other socioeconomic disparities in FA management among caregivers of children with FA remain unclear. ObjectiveTo determine associations between socioeconomic, clinical, and health care factors and FA-related knowledge, attitudes, and behaviors among caregivers of Black and White children with FA. DesignCross-sectional survey analysis from the Food Allergy Outcomes Related to White and African American Racial Differences Study. Participants/settingsLongitudinal cohort of caregivers of 385 Black and White children with FA ages birth to 12 years residing in Chicago, Illinois, Cincinnati, Ohio, and Washington, DC from 2017 to March 2021. Main outcome measuresThere were 3 primary outcomes of interest: (1) FA knowledge assessed by scores from the Knowledge Survey, (2) FA-related attitudes assessed by newly developed survey, and (3) food-related behaviors assessed by the FORWARD Diet and Purchasing Habit Surveys completed 6 months postenrollment. AnalysesMultivariable linear and logistic regression. ResultsThe overall response rate to the 6-month postenrollment survey was 51.3% (385 of 751). White caregivers represented 69.4% of the participants. Black race was associated with a 1.5-point mean decrease in FA knowledge score (95% CI: −2.2 to −0.7) compared with White caregivers, and a graduate degree or bachelor’s degree was associated with associated with a 1.7-point mean increase (95% CI: 0.8-2.7) and 1.1-point mean increase (95% CI: 0.2-2.0) in FA knowledge score, respectively, compared with caregivers who had less than a bachelor’s degree. Multiple FAs and ever visited the emergency department for a food-related allergic reaction were also associated with higher levels of FA knowledge. Ever visited the emergency department for FA was also associated with higher odds of 2 measures of FA attitudes reflecting parental anxiety. Greater FA knowledge scores were consistently associated with lower odds of several FA-related food purchasing and eating behaviors assumed to have elevated risk of FA. Eating food prepared at school was the only FA behavior associated with race. Compared with White children, Black children were 2.5 times more likely to eat school-prepared foods (95% CI: 1.2-5.6). ConclusionsFindings from this study identified socioeconomic, racial, and clinical factors associated with caregivers’ FA-related knowledge, attitudes, and behaviors, but further research is warranted to better understand these relationships.

Risk Factors Influencing Tolerance and Clinical Features of Food Protein-Induced Allergic Proctocolitis

To examine the clinical course and risk factors of food protein-induced allergic proctocolitis (FPIAP).A total of 257 infants who presented to 5 outpatient pediatric allergy or gastroenterology clinics with rectal bleeding and were given a diagnosis of FPIAP were included in the study.After enrollment, infants had serum immunoglobulin E testing, skin-prick testing (SPT), and complete blood cell count. Clinical characteristics were prospectively managed. Patients with other known gastrointestinal illnesses were excluded. Cow’s milk elimination was trialed first in both the infant’s diet as well as the mother’s diet if breastfeeding, and, if no improvement, egg was eliminated next. Combined elimination of wheat, nuts, and soy followed, if no improvement. Eliminated foods were then reintroduced after 2 to 4 weeks, and a worsening of symptoms confirmed diagnosis.There was no sex predominance, with 50.2% being female (n = 129). The vast majority were breastfed at diagnosis (97.2%), with 66.5% exclusively breastfed. Blood in stool was present in every case, and other common complaints were mucous in stool (n = 224) and loose stool (n = 168). Cow’s milk was the most common causative food, accounting for 99.2% of cases. Comparing those with only 1 food allergy (75.9%) versus those with multiple food allergies, children with a single-food allergy more often were exclusively breastfeeding at diagnosis, had a longer duration of breastfeeding, had less antibiotic use in the first 6 months, and had higher tolerance development (P = .003, < 0.001, < 0.001, and < 0.001, respectively). Immunoglobulin E (IgE) sensitization was assessed in 239 patients, and 55 (23%) had positive test results. Sensitized children less often developed tolerance to the offending allergen compared with nonsensitized children (52.4% versus 81.2%). Only 16 patients underwent endoscopy and were continued to be treated as having FPIAP.Most patients with FPIAP resolve within a year. Infants with colic, IgE sensitization, and multiple food allergies may be at risk for delayed tolerance. Cow’s milk should be the first excluded food in infants and breastfeeding mothers, and elimination should resolve symptoms in most patients. Breastfeeding and lower antibiotic use was associated with a decrease in the development of multiple food allergies. The role of SPT and IgE testing is still unclear and may not add benefit to most cases. Endoscopy did not change management, even in severe cases.This is an important study that characterizes a common condition. The prospective nature of this study is a strength, along with high retention of subjects throughout the study. The involvement of multiple centers and specialties introduced some variability in practice. More severe cases of FPIAP are likely represented in this study because subjects had referral to allergy or gastroenterology specialists. Also, the high prevalence of breastfeeding in this cohort may limit its generalizability to other communities; regional food preferences and breastfeeding prevalence may have a large effect on the development of allergies and food sensitization.

Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy

Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.

A Prospective Assessment of Clinical Characteristics and Responses to Dietary Elimination in Food Protein–Induced Allergic Proctocolitis

Some aspects of diagnostic elimination/challenge diets in food protein-induced allergic proctocolitis (FPIAP) are still poorly defined. This study investigated the symptom spectrum, time required for resolution of each symptom, triggering foods, and risk factors for multiple food allergies (MFA) in FPIAP. Infants referred with visible blood in stool were enrolled after etiologies other than FPIAP had been excluded. Laboratory evaluation, clinical features, and elimination/challenge steps were performed prospectively during diagnostic management. Ninety-one of 102 infants (53 boys) were diagnosed with FPIAP. Eleven children did not bleed during challenges. Visible blood in stool began before 2 months of age in 63.6% of the infants not diagnosed with FPIAP, compared with 18.9% of the patients with FPIAP (P= .003). Offending foods were identified as cow's milk (94.5%), egg (37.4%), beef (10.9%), wheat (5.5%), and nuts (3.3%). MFA was determined in 42.9% of patients. Multivariate logistic regression analysis identified atopic dermatitis (AD) (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.18-7.55, P= .021) and an eosinophil count ≥300 cells/μL (OR: 2.72, 95% CI: 1.09-6.80, P= .032) as independent risk factors for MFA. Blood and mucus in stool disappeared in a median 3 days (interquartile range [IQR]: 1-14.5 days) and 30 days (IQR: 8-75 days), respectively. A tendency to transient bleeding occurs in infants who present with bloody stool before 2 months of age. A 2-week duration of elimination for blood in stool is sufficient to reach a judgment of suspected foods for FPIAP. Mucus in stool is the last symptom to disappear. Concurrent AD suggests a high probability of MFA in FPIAP.

M239 CHALLENGE CONFIRMED ATYPICAL FOOD PROTEIN-INDUCED ENTEROCOLITIS SYNDROME (FPIES) TO AVOCADO IN AN INFANT

We present a case of challenge-confirmed atypical Food Protein-Induced Enterocolitis Syndrome (FPIES) to avocado in an infant with history of anaphylaxis to milk, who has a sibling with multiple anaphylactic food allergies.

P101 CHARACTERISTICS OF PATIENTS WITH SINGLE VERSUS MULTIPLE FOOD ALLERGIES FROM THE FARE PATIENT REGISTRY

Food allergies effect many patients in the US. Limited literature describes the characteristics of patients with single versus multiple food allergies. It is our hypothesis that characteristics differ between these groups and sought to evaluate that from registry data.

The Challenges of Managing Multiple Food Allergies and Consequent Food Aversions

The allergic march can often result in children with one food allergy phenotype developing other allergic manifestations as they grow older. In this grand round, we describe the case of a child with a diagnosis of eosinophilic esophagitis at an early age, who subsequently developed IgE-mediated allergy to milk and egg. Because of the onset of allergic rhinitis, an additional complication of the teenage years was the development of pollen food syndrome, which further affected the already complex dietary management. These multiple allergies had a consequent effect on nutritional status and provoked considerable psychosocial issues, which greatly affected the patient's relationship with food. This case illustrates that for complex patients, a cohesive approach and shared decision-making are essential for diagnosis and management. Working with the patient and also the whole family, and considering how best to support them, necessitates a flexible approach. Regular follow-up is important to address changing psychosocial and dietary needs and monitor the resolution of allergies and response to pharmacotherapy. Complex patients need the input of a comprehensive multidisciplinary team, with good access to dietetic and psychological support, to optimize quality of life for these individuals and their families.

Exploration of parent-reported food allergy symptoms via breastmilk exposures and likelihood to develop tolerance

BackgroundKnowledge is limited about the relationship between clinical reactivity to foods through breastfeeding and long-term food allergy outcomes. We explored parent-perceived symptoms of food allergy via breastfeeding and the association with future tolerance.MethodsSubjects identified from the Chicago Food Allergy Study (2005–2011) were categorized by parent-reported reactions to maternally ingested foods via breastfeeding (50/898 peanut-allergic, 69/620 egg-allergic, and 153/589 milk-allergic). The primary outcome was tolerance [passed oral food challenge (OFC) or consumption of previously implicated food]. Secondary outcomes included severe reactions (anaphylaxis and/or cardiovascular/respiratory symptoms) and additional concomitant food allergies. Univariate chi-square analyses were performed to assess for association between variables, followed by logistic regression models.ResultsOf the 50 subjects with parent-reported peanut-associated symptoms with breastfeeding, none gained tolerance. There were no significant associations between parent-reported breastfeeding symptoms and development of tolerance for egg and milk (egg: OR 0.46, 95% CI 0.21–1.01, p = 0.053; milk: OR 1.13, 95% CI 0.70–1.81, p = 0.614). All egg-allergic subjects with parent-perceived symptoms while breastfeeding also reported multiple food allergies (n = 69), but milk- and peanut-allergic subjects were not more likely to have multiple allergies (milk: OR 1.89, 95% CI 0.88–4.02, p = 0.10; peanut: OR 2.36, 95% CI 0.72–7.76, p = 0.16). There were no significant associations between parent-reported breastfeeding symptoms and subsequent reaction severity.ConclusionsA significant proportion of parents perceive symptoms of food allergy attributable to indirect breastfeeding exposures. Our exploratory analysis suggests that infants with parent-perceived clinical reactivity to peanut via breastmilk may be less likely to gain tolerance. Infants with parent-reported reactivity to egg via breastmilk exposure were more likely to report multiple food allergies. Further rigorous prospective studies are needed to clarify the true prevalence of IgE-mediated food allergy symptoms attributable to indirect breastfeeding exposures and the association with development of tolerance.

Description of two anaphylaxis phenotypes in children: The utility of a clustering analysis

Anaphylaxis appears to be heterogeneous with regards to patients’ characteristics, clinical manifestations, triggers, and severity. We set out to define anaphylaxis phenotypes using a non-supervised cluster analysis in children experiencing anaphylaxis. Characteristics of children (< 18 y) admitted for anaphylaxis to emergency care units in three French regions were recorded and 23 of these variables were analyzed in a clustering analysis. (See Fig. 1 ) Two hundre and twenty two (male: 62%, mean age: 7.9 y; SD: 5.1) children were included. Two anaphylaxis clusters have been described. Cluster 1, “Food (nuts) severe anaphylaxis in highly atopic children” ( n = 56, 25%): all children had food-induced anaphylaxis, most often induced by peanut (38%) and nuts (36%), and a previous food allergy to the same trigger (89%). These children had allergic comorbidities (multiple food allergy, 77%; asthma, 63%; atopic dermatitis, 36%) and had more severe anaphylaxis reactions (Ring score 3–4, 45%; adrenaline injection, 46%; hospital admission, 36%). Cluster 2, “Mild anaphylaxis with various triggers and few atopic comorbidities” ( n = 168, 75%): these children were younger ( p = 0.039), had less frequent allergic disease (asthma, 31%; food allergy, 16%; atopic dermatitis, 17%), with various triggers (food, 68%; drugs, 10%; insect venom, 7%) and less severe reactions (Ring 2, 78%; adrenaline injection, 26%; hospital admission, 20%). We confirm the heterogeneity of anaphylaxis in children. Children with allergic comorbidities and food triggers (nuts) are at risk of more severe anaphylaxis reactions as compared to children with less allergic disease and other triggers than food. Larger studies are required to confirm these anaphylaxis phenotypes in children.

An algorithm to safely manage oral food challenge in an office-based setting for children with multiple food allergies

Background: In France, from 30% to 35% of children suffer from multiple food allergies (MFA). The gold standard to diagnosis a food allergy is the oral food challenge (OFC) which is conducted in a hospital setting due to risk of anaphylaxis. The aim of this study was to evaluate an algorithm to predict OFCs at low risk of anaphylaxis that could safely be performed in an office-based setting. Methods: Children with MFA and at least one open OFC reactive or non-reactive to other allergens were included. The algorithm was based on multiple clinical and biological parameters related to food allergens, and designed mainly to predict “low-risk” OFCs i.e., practicable in an office-based setting. The algorithm was secondarily tested in a validation cohort. Results: Ninety-one children (median age 9 years) were included; 94% had at least one allergic comorbidity with an average of three OFCs per child. Of the 261 OFCs analyzed, most (192/261, 74%) were non-reactive. The algorithm failed to correctly predict 32 OFCs with a potentially detrimental consequence but among these only three children had severe symptoms. One hundred eighty-four of the 212 “low-risk” OFCs, (88%) were correctly predicted with a high positive predictive value (87%) and low negative predictive value (44%). These results were confirmed with a validation cohort giving a specificity of 98% and negative predictive value of 100%. Conclusion: This study suggests that the algorithm we present here can predict “low-risk” OFCs in children with MFA which could be safely conducted in an office-based setting. Our results must be confirmed with an algorithm-based machine-learning approach.

Treating Food Allergies One Bite At A Time

My 10-year-old daughter had just returned home from sleepaway camp. Yes, a child with multiple food allergies (eggs, sesame, tree nuts, flax seed, shellfish, mustard, and canola oil) spent 7 weeks away from home. With the guidance and encouragement of one of the leading allergists in the United States, I took his advice.

Most Burdensome Food Allergy in Childcare Centers and Schools: A Cross-sectional Study

Objective: In this mixed-methods study, we aimed to identify the food allergen with the greatest reported burden to families with preschool and school-aged food allergic children. Methods: Parents of children with 2+ food allergies responded to an online, anonymous study on the burden of multiple food allergies. We used descriptive statistics and thematic analysis to analyze the quantitative and qualitative data, respectively. Results: A total of 123 parents participated. The 4 most prevalent food allergies among preschoolers (preschoolers 0-5 years: N = 46; 37.4%) were egg (78.3%), milk (69.6%), peanut (60.9%) and tree nut (54.3%). These were also the most common allergies among school-aged children school-aged 6-18 years; N = 77; 62.6%), albeit in different proportions. Milk was reported as the most stressful food allergy in childcare centers (71.9%), whereas parents of school-aged children reported more comparable distributions of the most stressful food allergy at schools. Qualitatively, we identified one theme per age group: “Peanut is easy to avoid, but milk is everywhere” for preschoolers, and “Every food allergy for school-aged children.” Conclusions: The burden associated with types of food allergy differs between preschool and school-aged children.

Induction of food tolerance is dependent on intestinal inflammatory state

Food allergies are usually managed by food avoidance. Hidden allergens in food, due to cross-contamination and/or allergenic additives added during production, place an important concern in today’s increasing food allergy cases worldwide. Previous studies showed that the introduction of unacquainted food components, in an inflamed intestine, results in sensitization to this food. Thus, our aim was to evaluate the kinetics of multiple food allergy induction. Adult male C57BL/6 mice were divided into five groups, four of which were submitted to an intestinal inflammation induction protocol to peanuts. Egg white (OVA) diluted 1:5 v/v in distilled water was instilled by gavage 6h-before (PRIOR), concomitant (AT) and 6h-after (DURING) the onset of the peanut challenge diet. Positive control (POS CONT) and NEG CONT received saline per gavage. Finally, animals were challenged with subcutaneous injections of OVA. Results showed no changes in diet intake were observed. Anti-OVA polyisotypic IgG antibody titers significantly increased in AT. Flow cytometry revealed significant decrease in CD4+CD25+Foxp3+ and significant increase in TCD8+ in AT. Histomorphometrically, AT and DURING were classified as Infiltrative and Partial Destruction stages. PRIOR was classified as Infiltrative, while POS CONT was classified as Partial Destruction. NEG CONT was classified as Normal. Together, our results confirm that the introduction of unfamiliar food only a few hours before the initiation of a gut inflammation process is able to induce oral tolerance, however the introduction of a dietary protein concomitant to the onset or during an ongoing gut inflammation may induce multiple allergies.

Mycosis Fungoides in 2 Pediatric Patients with Atopic Dermatitis

A 16-year-old girl with a lifetime history of atopic dermatitis (AD) and multiple food allergies presented with complaints of worsening dermatitis over several months in the setting of 2 weeks of chills, total body redness with mild pruritus, and hair shedding. Physical examination demonstrated erythroderma, scaly plaques, overlying firm skin-colored papules (Figures 1 and 2), thinning hair of the scalp and eyebrows, and cervical and inguinal lymphadenopathy. Skin biopsy was pursued given unusual presentation, including pruritus that was less than expected for AD.

Real life study of the use of omalizumab for pediatric patients with multiple food allergies.

Multiple food allergies (MFAs) affect 30% of the child population with food allergy. The current treatment is the exclusion diet, which frequently affects the quality of life for these patients. The objective of the study was to describe the effect of omalizumab treatment in children diagnosed with MFAs who experienced frequent anaphylactic reactions and the impact on their quality of life. A descriptive observational study. Patients with severe food restrictions and high-risk due to multiple episodes of anaphylaxis were included. The allergy was confirmed by compatible clinical, skin tests, positive specific IgE and oral food challenges (OFCs). Omalizumab treatment was initiated and the impact on the life quality of patients and their families was assessed using the validated Food Allergy Quality of Life Questionnaire-Parent Form. Five patients with an average age at diagnosis of 3.58 years (range between 1.5-7.9 years), were diagnosed with MFAs. All patients presented with anaphylaxis. All patients were treated with omalizumab between 2013 and 2019. Omalizumab treatment was initiated at a mean age of 6.05 years (range between 4.5-8.25 years). All patients have undergone OFC to reintroduce food successfully. 2 patients had their dose of omalizumab reduced by half, and 1 patient has had the time interval extended between administrations due to the maintenance of food tolerance. No immediate local or systemic adverse reactions were documented. Two patients have commenced omalizumab administration at home without incident. Children with MFAs who are treated with omalizumab do not show reactions in response to most of the foods to which they previously had anaphylaxis. Consequently, these patients were able to significantly expand the variety of their diet, improving the life quality and avoid anaphylaxis following the inadvertent intake of these foods.

An Unusual Case of Multiple Food Allergies Comorbid with Multiple Chemical Sensitivity: A Case Report

PurposeTo report the case of a patient with multiple food allergies comorbid with multiple chemical sensitivity (MCS) who was misdiagnosed on various occasions, resulting in a negative impact on the patient’s personal and social life.Case ReportWe present the case of a 43-year-old Colombian women with multiple food allergies concomitant with MCS. Symptoms started with a mild reaction to insecticides, car exhaust smoke, and perfumes and gradually evolved into a severe reaction to her environment. She also presented recurrent episodes of clinical reactivity to foods and persistent elevated IgE levels, as well as several life-threatening anaphylactic reactions. Alternative and allopathic therapies were applied, but her symptoms persisted. Various diagnoses were made before the definitive diagnosis.ConclusionMCS is an unusual entity of unknown pathophysiology that can, on rare occasions, coexist with food allergies. Early recognition and multidisciplinary treatment are required as these entities have a major impact on the patient’s quality of life. We present the first Latin American case regarding the association of the two diseases.

A remarkable food allergy in children: cashew nut allergy.

The prevalence of cashew nut allergy is increasing. Clinical reaction to cashew nuts may be severe, including anaphylaxis. In this study, we aimed to evaluate the frequency of cashew nut sensitivity in a group of children with food allergy and the clinical features and course of cashew nut allergy. A retrospective chart review was performed on 516 children who presented with food allergy at a pediatric allergy department. Individuals sensitized to cashew nuts were examined. Cashew nut sensitization was detected in 17 (64.7% male; mean age of symptom onset, 14 months) of 516 patients with food allergy. Skin symptoms were the most frequent clinical presentation, followed by gastrointestinal symptoms. Overall, 29.4% of the patients presented with anaphylaxis. All anaphylactic reactions were developed after the first consumption of cashew nuts. Of the cashew nut-sensitized patients, 82.3% were diagnosed with moderate-to-severe atopic dermatitis, and all of them had multiple food allergies. During the follow-up, 90% of the patients who had cashew nut sensitization and co-existing food allergies to cow's milk and/or hen's egg developed tolerance to cow's milk and/or hen's egg, but none of the patients could tolerate cashew nut ingestion. Cashew nut is a potent allergen, causing severe allergic reactions that persist long term compared with other food allergies. Early onset of moderate-to-severe atopic dermatitis and multiple food allergies are remarkable co-existing conditions in children who have been diagnosed with cashew nut allergy. Pediatricians should be aware of this emerging food allergy.