Dr.Janice Joneja. Success with Food Allergy and Intolerance.
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Dr.Janice Joneja. Success with Food Allergy and Intolerance.

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Lecture 1. Diagnosis and Management

Lecture 1. Diagnosis and Management

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Dr.Janice Joneja. Success with Food Allergy and Intolerance. Dr.Janice Joneja. Success with Food Allergy and Intolerance. Presentation Transcript

  • SUCCESS WITH FOODSUCCESS WITH FOOD ALLERGY AND INTOLERANCEALLERGY AND INTOLERANCE Janice Joneja Ph.D., RDJanice Joneja Ph.D., RD
  • 2 Food Allergy & Food IntoleranceFood Allergy & Food Intolerance DEFINITIONS:DEFINITIONS: Food Allergy An immunologic reaction resulting from the ingestion of a food or food additive Food Intolerance A generic term describing an abnormal physiological response to an ingested food or food additive which is not immunogenic
  • 3 Symptoms of Food AllergySymptoms of Food Allergy  Controversy among practitioners because there areControversy among practitioners because there are no definitive tests for food allergyno definitive tests for food allergy  Symptoms appear in diverse organ systems:Symptoms appear in diverse organ systems:  Skin and mucous membranesSkin and mucous membranes  Digestive tractDigestive tract  Respiratory tractRespiratory tract  Systemic (anaphylaxis)Systemic (anaphylaxis)  Symptoms in nervous system are considered moreSymptoms in nervous system are considered more subjective and sometimes may be dismissed assubjective and sometimes may be dismissed as fictitious or psychosomaticfictitious or psychosomatic
  • 4 Examples of Allergic ConditionsExamples of Allergic Conditions and Symptomsand Symptoms  Skin and Mucous MembranesSkin and Mucous Membranes  Atopic dermatitis (eczema)Atopic dermatitis (eczema)  Urticaria (hives)Urticaria (hives)  Angioedema (swelling of tissues, especially mouth andAngioedema (swelling of tissues, especially mouth and face)face)  Pruritus (itching)Pruritus (itching)  Contact dermatitis (rash in contact with allergen)Contact dermatitis (rash in contact with allergen)  Oral symptoms (irritation and swelling of tissuesOral symptoms (irritation and swelling of tissues around and inside thearound and inside the mouth)mouth)  Oral allergy syndromeOral allergy syndrome
  • 5 Examples of Allergic ConditionsExamples of Allergic Conditions and Symptomsand Symptoms  Digestive TractDigestive Tract  DiarrheaDiarrhea  ConstipationConstipation  Nausea and VomitingNausea and Vomiting  Abdominal bloating and distensionAbdominal bloating and distension  Abdominal painAbdominal pain  Indigestion (heartburn)Indigestion (heartburn)  BelchingBelching
  • 6 Examples of Allergic ConditionsExamples of Allergic Conditions and Symptomsand Symptoms  Respiratory TractRespiratory Tract  Seasonal or perennial rhinitis (hayfever)Seasonal or perennial rhinitis (hayfever)  Rhinorrhea (runny nose)Rhinorrhea (runny nose)  Allergic conjunctivitis (itchy, watery, reddened eyes)Allergic conjunctivitis (itchy, watery, reddened eyes)  Serous otitis media (earache with effusion) [“gum ear”;Serous otitis media (earache with effusion) [“gum ear”; “glue ear”]“glue ear”]  AsthmaAsthma  Laryngeal oedema (throat tightening due to swelling ofLaryngeal oedema (throat tightening due to swelling of tissues)tissues)
  • 7 Examples of Allergic ConditionsExamples of Allergic Conditions and Symptomsand Symptoms  Nervous SystemNervous System  MigraineMigraine  Other headachesOther headaches  Spots before the eyesSpots before the eyes  ListlessnessListlessness  HyperactivityHyperactivity  Lack of concentrationLack of concentration  Tension-fatigue syndromeTension-fatigue syndrome  IrritabilityIrritability  ChillinessChilliness  DizzinessDizziness
  • 8 Examples of Allergic ConditionsExamples of Allergic Conditions and Symptomsand Symptoms  OtherOther  Urinary frequencyUrinary frequency  Bed-wettingBed-wetting  HoarsenessHoarseness  Muscle achesMuscle aches  Low-grade feverLow-grade fever  Excessive sweatingExcessive sweating  PallorPallor  Dark circles around the eyesDark circles around the eyes
  • 9 AnaphylaxisAnaphylaxis  Severe reaction of rapid onset, involvingSevere reaction of rapid onset, involving most organ systems, which results inmost organ systems, which results in circulatory collapse and drop in bloodcirculatory collapse and drop in blood pressurepressure  In the most extreme cases the reactionIn the most extreme cases the reaction progresses to anaphylactic shock withprogresses to anaphylactic shock with cardiovascular collapsecardiovascular collapse  This can be fatalThis can be fatal
  • 10 AnaphylaxisAnaphylaxis  Usual progress of reactionUsual progress of reaction  Burning, itching and irritation of mouth and oral tissuesBurning, itching and irritation of mouth and oral tissues and throatand throat  Nausea, vomiting, abdominal pain, diarrheaNausea, vomiting, abdominal pain, diarrhea  Feeling of malaise, anxiety, generalized itching,Feeling of malaise, anxiety, generalized itching, faintness, body feels warmfaintness, body feels warm  Nasal irritation and sneezing, irritated eyesNasal irritation and sneezing, irritated eyes  Hives, swelling of facial tissues, reddeningHives, swelling of facial tissues, reddening  Chest tightness, bronchospasm, hoarsenessChest tightness, bronchospasm, hoarseness  Pulse is rapid, weak, irregular, difficult to detectPulse is rapid, weak, irregular, difficult to detect  Loss of consciousnessLoss of consciousness  Death may result from suffocation, cardiac arrhythmia,Death may result from suffocation, cardiac arrhythmia, or shockor shock
  • 11 Foods and AnaphylaxisFoods and Anaphylaxis  Almost any food can cause anaphylactic reactionAlmost any food can cause anaphylactic reaction  Some foods more common than others:Some foods more common than others:  PeanutPeanut  Tree nutsTree nuts  ShellfishShellfish  FishFish  EggEgg  In children under three yearsIn children under three years  Cow’s milkCow’s milk  EggEgg  WheatWheat  ChickenChicken
  • 12 Exercise-induced AnaphylaxisExercise-induced Anaphylaxis  Usually occurs within two hours of eating theUsually occurs within two hours of eating the allergenic foodallergenic food  Onset during physical activityOnset during physical activity  Foods most frequently reported to have inducedFoods most frequently reported to have induced exercise-induced anaphylaxis:exercise-induced anaphylaxis:  Wheat (omega-5-gliadin) and other grainsWheat (omega-5-gliadin) and other grains  Celery and other vegetablesCelery and other vegetables  Shellfish (shrimp; oysters)Shellfish (shrimp; oysters)  ChickenChicken  SquidSquid  Peaches and other fruitsPeaches and other fruits  Nuts especially hazelnutNuts especially hazelnut  Peanuts and soy beansPeanuts and soy beans  May be associated with aspirin ingestionMay be associated with aspirin ingestion
  • 13 Emergency Treatment forEmergency Treatment for Anaphylactic ReactionAnaphylactic Reaction  Injectable adrenalin (epinephrine)Injectable adrenalin (epinephrine)  Fast-acting antihistamine (e.g. Benadryl)Fast-acting antihistamine (e.g. Benadryl)  Usually in form of TwinJectUsually in form of TwinJect®® or Epipenor Epipen®®  Transport to hospital immediatelyTransport to hospital immediately  Second phase of reaction is sometimes fatal,Second phase of reaction is sometimes fatal, especially in an asthmaticespecially in an asthmatic  Patient may appear to be recovering, but 2-4 hoursPatient may appear to be recovering, but 2-4 hours later symptoms increase in severity and reactionlater symptoms increase in severity and reaction progresses rapidlyprogresses rapidly
  • 14 Immunologically MediatedImmunologically Mediated ReactionsReactions  IgE-mediated:IgE-mediated:  Immediate onset (anaphylaxis)Immediate onset (anaphylaxis)  Oral allergy syndrome (OAS)Oral allergy syndrome (OAS)  Latex-Food syndromeLatex-Food syndrome  Non-IgE-mediatedNon-IgE-mediated  Eosinophilic gastrointestinal diseasesEosinophilic gastrointestinal diseases  Food protein-sensitive enteropathiesFood protein-sensitive enteropathies  Gluten-sensitive enteropathy (celiac disease)Gluten-sensitive enteropathy (celiac disease)
  • 15 Role of the DietitianRole of the Dietitian  Accurate identification of the foodsAccurate identification of the foods responsibleresponsible  Elimination and challenge to confirm or refute:Elimination and challenge to confirm or refute:  allergy testsallergy tests  suspected allergens and intolerance triggerssuspected allergens and intolerance triggers  Directives for avoidance of the culprit foodsDirectives for avoidance of the culprit foods  Recognition of sources of the offendersRecognition of sources of the offenders  Understanding new labelling lawsUnderstanding new labelling laws
  • 16 The Dietitian’s RoleThe Dietitian’s Role  Provide guidelines and resources to ensure completeProvide guidelines and resources to ensure complete balanced nutrition from alternative foodsbalanced nutrition from alternative foods  MacronutrientsMacronutrients  MicronutrientsMicronutrients  Directives for prevention of food allergy andDirectives for prevention of food allergy and induction of oral toleranceinduction of oral tolerance  New guidelinesNew guidelines  Ensure freedom from allergens in food provision andEnsure freedom from allergens in food provision and preparation servicespreparation services
  • Tests for Adverse ReactionsTests for Adverse Reactions to Foodsto Foods Rationale and LimitationsRationale and Limitations
  • 18 Skin Tests:Skin Tests: Value in PracticeValue in Practice  Positive predictive accuracy of skin testsPositive predictive accuracy of skin tests rarely exceeds 50%rarely exceeds 50%  Many practitioners rate them lowerMany practitioners rate them lower  Negative skin tests do not rule out theNegative skin tests do not rule out the possibility of non-IgE-mediated reactionspossibility of non-IgE-mediated reactions  Do not rule out non-immune-mediated foodDo not rule out non-immune-mediated food intolerancesintolerances
  • 19 Value of SkinValue of Skin Tests in PracticeTests in Practice  Tests for highly allergenic foods thought toTests for highly allergenic foods thought to have close to 100%have close to 100% negativenegative predictivepredictive accuracy for diagnosis of IgE-mediatedaccuracy for diagnosis of IgE-mediated reactionsreactions  Such foods include:Such foods include:  EggEgg  MilkMilk  FishFish  WheatWheat  Tree nutsTree nuts  PeanutPeanut
  • 20 Blood TestsBlood Tests  RAST: radioallergosorbent test (e.g. ImmunoCap-RAST;RAST: radioallergosorbent test (e.g. ImmunoCap-RAST; Phadebas-RAST)Phadebas-RAST)  FAST; Fluorescence allergosorbent testFAST; Fluorescence allergosorbent test  ELISA: enzyme-linked immunosorbent assayELISA: enzyme-linked immunosorbent assay  Designed to detect and measure levels of allergen-specificDesigned to detect and measure levels of allergen-specific antibodiesantibodies  Used for detection of levels of allergen-specific IgEUsed for detection of levels of allergen-specific IgE  May measure total IgE - thought to be indicative of “atopicMay measure total IgE - thought to be indicative of “atopic potential”potential”  Some practitioners measure IgGSome practitioners measure IgG (especially IgG4(especially IgG4)) by ELISAby ELISA
  • 21 Value of Blood Tests in PracticeValue of Blood Tests in Practice  Blood tests have about the same sensitivity as skinBlood tests have about the same sensitivity as skin tests for identification of IgE-mediated sensitisationtests for identification of IgE-mediated sensitisation to food allergensto food allergens  There is often poor correlation between high level ofThere is often poor correlation between high level of anti-food IgE and symptoms when the food is eatenanti-food IgE and symptoms when the food is eaten  Many people with clinical signs of food allergy showMany people with clinical signs of food allergy show no elevation in IgEno elevation in IgE  Reasons for failure of blood tests to indicate foodsReasons for failure of blood tests to indicate foods responsible for symptoms are the same as those forresponsible for symptoms are the same as those for skin testsskin tests
  • 22 Value of Blood Tests in PracticeValue of Blood Tests in Practice  Anti-food antibodies (especially IgG) areAnti-food antibodies (especially IgG) are frequently detectable in all humans,frequently detectable in all humans, usually without any evidence of adverseusually without any evidence of adverse effecteffect  IgG production is likely to be the firstIgG production is likely to be the first stage of development of oral tolerance to astage of development of oral tolerance to a foodfood  Studies suggest that IgG4 indicatesStudies suggest that IgG4 indicates protection or recovery from IgE-mediatedprotection or recovery from IgE-mediated food allergyfood allergy
  • 23 Tests for Intolerance of Food AdditivesTests for Intolerance of Food Additives  There are no reliable skin or blood tests to detect foodThere are no reliable skin or blood tests to detect food additive intoleranceadditive intolerance  Skin prick tests forSkin prick tests for sulphitessulphites are sometimes positiveare sometimes positive  A negative skin test does not rule out sulphiteA negative skin test does not rule out sulphite sensitivitysensitivity  History and oral challenge provocation of symptomsHistory and oral challenge provocation of symptoms are the only methods for the diagnosis of additiveare the only methods for the diagnosis of additive sensitivity at presentsensitivity at present  CautionCaution: Challenge may occasionally induce: Challenge may occasionally induce anaphylaxis in sulphite-sensitive asthmaticsanaphylaxis in sulphite-sensitive asthmatics
  • 24 Commercial Testing and Food AllergyCommercial Testing and Food Allergy Management ProgramsManagement Programs  LEAP (Lifestyle Eating and Performance);LEAP (Lifestyle Eating and Performance); Signet Diagnostic CorporationSignet Diagnostic Corporation  Claims to “successfully treat … IBS, migraines,Claims to “successfully treat … IBS, migraines, fibromyalgia, autism, ADD/ADHD, IBD, urticaria,fibromyalgia, autism, ADD/ADHD, IBD, urticaria, chronic fatigue syndrome, obesity, etc.”chronic fatigue syndrome, obesity, etc.”  Negative aspects:Negative aspects:  Testing based on “mediator release”Testing based on “mediator release”  Not a recognized accurate method for allergy testingNot a recognized accurate method for allergy testing  Positive aspectsPositive aspects  Management includes elimination and challenge, foodManagement includes elimination and challenge, food substitutions and meal planningsubstitutions and meal planning
  • 25 Commercial Testing and Food AllergyCommercial Testing and Food Allergy Management ProgramsManagement Programs  Gemoscan Corporation:Gemoscan Corporation:  HEMOCODE™ (Gemoscan) Food Intolerance System,HEMOCODE™ (Gemoscan) Food Intolerance System, and MenuWise™ Food Intolerance Plan “personalizedand MenuWise™ Food Intolerance Plan “personalized naturopathic nutritional programs that promote well-naturopathic nutritional programs that promote well- being.”being.”  Available in retail stores (Rexall and Loblaws)  Price is $450 for 250 foods  Tests identify IgG antibody to foods  Customers receive support from pharmacist/naturopath, including consultation on appropriate vitamins and supplements  Negative aspects  There is no provision for dietetic counselling and thus a high risk for nutritional deficiency when the “reactive foods” are eliminated without sufficient knowledge to provide nutrients from alternate sources
  • 26 Unorthodox TestsUnorthodox Tests  Many people turn to unorthodox tests whenMany people turn to unorthodox tests when avoidance of foods positive by conventional testavoidance of foods positive by conventional test methods have been unsuccessful in managing theirmethods have been unsuccessful in managing their symptomssymptoms  Tests include:Tests include:  Vega test (electro-dermal)Vega test (electro-dermal)  Biokinesiology (muscle strength)Biokinesiology (muscle strength)  Analysis of hair, urine, salivaAnalysis of hair, urine, saliva  RadionicsRadionics  ALCAT (lymphocyte cytotoxicity)ALCAT (lymphocyte cytotoxicity)
  • 27 Drawbacks of Unreliable TestsDrawbacks of Unreliable Tests  Diagnostic inaccuracyDiagnostic inaccuracy  Therapeutic failureTherapeutic failure  False diagnosis of allergyFalse diagnosis of allergy  Creation of fictitious disease entitiesCreation of fictitious disease entities  Failure to recognize and treat genuine diseaseFailure to recognize and treat genuine disease  Inappropriate and unbalanced dietsInappropriate and unbalanced diets  Risk of nutritional deficiencies and diet-Risk of nutritional deficiencies and diet- related diseaserelated disease
  • Non-IgE-MediatedNon-IgE-Mediated AllergiesAllergies Eosinophilic Gastrointestinal DiseasesEosinophilic Gastrointestinal Diseases Food Protein Induced EnteropathiesFood Protein Induced Enteropathies
  • 29 Eosinophilic GastrointestinalEosinophilic Gastrointestinal Diseases (EGID)Diseases (EGID)  Expanded definition of food allergy nowExpanded definition of food allergy now encompasses any immunological response to foodencompasses any immunological response to food components that results in symptoms when the foodcomponents that results in symptoms when the food is consumedis consumed  Example is group of conditions in the digestive tractExample is group of conditions in the digestive tract in which infiltration of eosinophils is diagnosticin which infiltration of eosinophils is diagnostic  Collectively these diseases are becoming known asCollectively these diseases are becoming known as eosinophilic gastrointestinal diseases (EGID).eosinophilic gastrointestinal diseases (EGID).
  • 30 Characteristics of EGIDCharacteristics of EGID  Inflammatory mediators are released fromInflammatory mediators are released from the eosinophils, and act on local tissues inthe eosinophils, and act on local tissues in the esophagus and gastrointestinal tract,the esophagus and gastrointestinal tract, causing inflammationcausing inflammation  In eosinophilic digestive diseases there is noIn eosinophilic digestive diseases there is no evidence of IgE, therefore tests for IgE-evidence of IgE, therefore tests for IgE- mediated allergy are usually negativemediated allergy are usually negative  Unless there is a concomitant IgE-mediatedUnless there is a concomitant IgE-mediated reaction to foodreaction to food
  • 31 Eosinophilic EsophagitisEosinophilic Esophagitis  Symptoms most frequently associated with EOSymptoms most frequently associated with EO and considered to be typical of the disease include:and considered to be typical of the disease include:  VomitingVomiting  Regurgitation of foodRegurgitation of food  Difficulty in swallowing: foods are said to be stickingDifficulty in swallowing: foods are said to be sticking on the way downon the way down  Choking on foodChoking on food  Heartburn and chest painHeartburn and chest pain  Water brash (regurgitation of a watery fluid notWater brash (regurgitation of a watery fluid not containing food material)containing food material)  Poor eatingPoor eating  Failure to thrive (poor or no weight gain, or weightFailure to thrive (poor or no weight gain, or weight loss)loss)
  • 32 Eosinophilic EsophagitisEosinophilic Esophagitis  Although the symptoms resemble gastro-Although the symptoms resemble gastro- esophageal reflux disease (GERD), theesophageal reflux disease (GERD), the reflux of EO dose not respond to thereflux of EO dose not respond to the medications used to suppress the gastricmedications used to suppress the gastric acid and control regurgitation (antirefluxacid and control regurgitation (antireflux therapy) in GERDtherapy) in GERD  There is emerging data to suggest that useThere is emerging data to suggest that use of acid-suppressing medications mayof acid-suppressing medications may predispose patients to the development ofpredispose patients to the development of EoEEoE
  • 33 Diagnosis of EoEDiagnosis of EoE Three criteria must be met:Three criteria must be met:  Clinical symptoms of esophagealClinical symptoms of esophageal dysfunctiondysfunction  Oesophageal biopsy with an eosinophilOesophageal biopsy with an eosinophil count of at least 15 eosinophils per high-count of at least 15 eosinophils per high- power (x400 mag) microscopy fieldpower (x400 mag) microscopy field  Exclusion of other possible causes of theExclusion of other possible causes of the conditioncondition Dellon ES 2013
  • 34 Eosinophilic EsophagitisEosinophilic Esophagitis Foods most frequently implicatedFoods most frequently implicated in Childrenin Children  EggEgg  Cow’s milkCow’s milk  SoySoy  WheatWheat  CornCorn  PeanutsPeanuts  Tree nutsTree nuts  ShellfishShellfish  FishFish  BeefBeef  RyeRye
  • 35 Six-Food Elimination Diet and EoESix-Food Elimination Diet and EoE Adult study 2013Adult study 2013  Foods eliminated:Foods eliminated:  CerealsCereals  WheatWheat  RiceRice  CornCorn  Milk and milk productsMilk and milk products  EggsEggs  Fish and seafoodFish and seafood  Legumes including peanutsLegumes including peanuts  SoySoy Lucendo et al 2013
  • 36 Six-Food Elimination Diet andSix-Food Elimination Diet and EoEEoE  Indicators of positive outcome:Indicators of positive outcome:  Biopsy eosinophil count (Biopsy eosinophil count (< 15/hpf)< 15/hpf)  Negative gastro-oesophageal refluxNegative gastro-oesophageal reflux  Reduced eosinophil count: 73.1% of subjectsReduced eosinophil count: 73.1% of subjects  Maintained remission for 3 yearsMaintained remission for 3 years  Incidence of single triggering factors:Incidence of single triggering factors:  Cow’s milk 61.9%Cow’s milk 61.9%  Wheat 28.6%Wheat 28.6%  Eggs 26.2%Eggs 26.2%  Legumes 23.8%Legumes 23.8%  No correlation with allergy testsNo correlation with allergy tests
  • 37 Eosinophilic Gastroenteritis:Eosinophilic Gastroenteritis: Diagnosis by biopsy:Diagnosis by biopsy: Abnormal number of eosinophils in theAbnormal number of eosinophils in the stomach and small intestinestomach and small intestine Foods most frequently implicatedFoods most frequently implicated  EggEgg  Cow’s milkCow’s milk  SoySoy  WheatWheat  PeanutsPeanuts  Tree nutsTree nuts  ShellfishShellfish  FishFish
  • 38 Eosinophilic ProctocolitisEosinophilic Proctocolitis Diagnosis by biopsy:Diagnosis by biopsy: Abnormal number of Eosinophils confined to theAbnormal number of Eosinophils confined to the coloncolon Foods most frequently implicatedFoods most frequently implicated  Cow’s milkCow’s milk  Soy proteinsSoy proteins Most frequently develops within the first 60 days of lifeMost frequently develops within the first 60 days of life Is a non-IgE-mediated conditionIs a non-IgE-mediated condition
  • 39 Food Protein EnteropathiesFood Protein Enteropathies  Increasing recognition of a group of non-IgE-Increasing recognition of a group of non-IgE- mediated food-related gastrointestinal problemsmediated food-related gastrointestinal problems associated with delayed or chronic reactionsassociated with delayed or chronic reactions  Conditions include:Conditions include:  Food protein induced enterocolitis syndromeFood protein induced enterocolitis syndrome (FPIES)(FPIES)  Food protein induced proctocolitis (FPIP)Food protein induced proctocolitis (FPIP)  These digestive disorders tend to:These digestive disorders tend to:  Appear in the first months of lifeAppear in the first months of life  Be generally self-limitingBe generally self-limiting  Typically resolve at about two years of ageTypically resolve at about two years of age
  • 40 FPIES SymptomsFPIES Symptoms Symptoms in infants typically include:Symptoms in infants typically include:  Profuse vomitingProfuse vomiting  Diarrhoea, which can progress to dehydration andDiarrhoea, which can progress to dehydration and shock in severe casesshock in severe cases  Increased intestinal permeabilityIncreased intestinal permeability  MalabsorptionMalabsorption  DysmotilityDysmotility  Abdominal painAbdominal pain  Failure to thrive (typically weight gain less thanFailure to thrive (typically weight gain less than 10 g/day)10 g/day)  In severe episodes the child may be hypothermicIn severe episodes the child may be hypothermic (<36 degrees C)(<36 degrees C)
  • 41 FPIES CharacteristicsFPIES Characteristics  Triggered by foods, but not mediated by IgETriggered by foods, but not mediated by IgE  Condition typically develops in response to foodCondition typically develops in response to food proteins as a result of digestive tract andproteins as a result of digestive tract and immunological immaturityimmunological immaturity  Cow’s milk and soy proteins, usually given inCow’s milk and soy proteins, usually given in infant formulae, reported as most frequent causesinfant formulae, reported as most frequent causes  Milk and soy-associated FPIES usually startsMilk and soy-associated FPIES usually starts within the first year of life; most frequently withinwithin the first year of life; most frequently within the first six or seven monthsthe first six or seven months  When solids foods are introduced, other foodsWhen solids foods are introduced, other foods may cause the conditionmay cause the condition  Recent research claims that rice is the mostRecent research claims that rice is the most common food causing FPIEScommon food causing FPIES
  • 42 Foods Associated with FPIESFoods Associated with FPIES Removal of the culprit foods usually leads toRemoval of the culprit foods usually leads to immediate recovery from the symptomsimmediate recovery from the symptoms Foods that have been identified as triggers of FPIESFoods that have been identified as triggers of FPIES in individual cases include:in individual cases include:  MilkMilk  Cereals (oats, barley and rice)Cereals (oats, barley and rice)  Legumes (peas, peanuts, soy, lentils)Legumes (peas, peanuts, soy, lentils)  Vegetables (sweet potato, squash)Vegetables (sweet potato, squash)  Poultry (chicken, turkey)Poultry (chicken, turkey)  EggEgg
  • 43 Prevention of FPIESPrevention of FPIES  Most reports of FPIES indicate that exclusiveMost reports of FPIES indicate that exclusive breast-feeding is protective in potential cases ofbreast-feeding is protective in potential cases of FPIESFPIES  None of the infants who later developed FPIESNone of the infants who later developed FPIES after the introduction of solids had symptomsafter the introduction of solids had symptoms while being exclusively breast-fedwhile being exclusively breast-fed  Authors of these studies suggest that babies withAuthors of these studies suggest that babies with FPIES while being breast-fed were sensitized toFPIES while being breast-fed were sensitized to the proteins through an infant formula giventhe proteins through an infant formula given during a period of immunological susceptibilityduring a period of immunological susceptibility
  • 44 Diagnosis and Management of FPIESDiagnosis and Management of FPIES  There are no diagnostic tests for FPIES atThere are no diagnostic tests for FPIES at presentpresent  Indicators include clinical presentation :Indicators include clinical presentation :  development of acute symptoms immediatelydevelopment of acute symptoms immediately after consumption of the offending foodsafter consumption of the offending foods (often milk- or soy-based infant formula)(often milk- or soy-based infant formula)  absence of positive tests for food allergyabsence of positive tests for food allergy  Elimination and challenge with the suspectElimination and challenge with the suspect foods will usually confirm the syndromefoods will usually confirm the syndrome
  • 45 Diagnosis and Management of FPIESDiagnosis and Management of FPIES  Removal of the offending food leads toRemoval of the offending food leads to symptom resolutionsymptom resolution  In most cases delayed introduction of solidIn most cases delayed introduction of solid foods is advised because of the possibility thatfoods is advised because of the possibility that until the child’s immune system has matured, auntil the child’s immune system has matured, a similar reaction to proteins in other foods maysimilar reaction to proteins in other foods may elicit the same responseelicit the same response
  • 46 Food Protein InducedFood Protein Induced Proctitis/ProctocolitisProctitis/Proctocolitis  Blood in the stool is typicalBlood in the stool is typical  Condition typically appears in the first few monthsCondition typically appears in the first few months of life, on average at the age of two monthsof life, on average at the age of two months  TheThe absenceabsence of other symptoms, such as vomiting,of other symptoms, such as vomiting, diarrhoea, and lack of weight gain (failure todiarrhoea, and lack of weight gain (failure to thrive) usually rules out other causes such as foodthrive) usually rules out other causes such as food allergy, and food protein enteropathiesallergy, and food protein enteropathies  Usually the blood loss is very slight, and anaemiaUsually the blood loss is very slight, and anaemia as a consequence of loss of blood is rareas a consequence of loss of blood is rare  Diagnosis is usually made after other conditionsDiagnosis is usually made after other conditions that could account for the blood, such as analthat could account for the blood, such as anal fissure and infection, have been ruled outfissure and infection, have been ruled out
  • 47 Food Triggers of FPIPFood Triggers of FPIP  Most common triggers of FPIP include:Most common triggers of FPIP include:  Cow’s milk proteinsCow’s milk proteins  Soy proteinsSoy proteins  Occasionally eggOccasionally egg  Many babies develop the symptoms duringMany babies develop the symptoms during breast-feeding in response to milk and soybreast-feeding in response to milk and soy in the mother’s dietin the mother’s diet
  • 48 Causes and Management ofCauses and Management of FPIPFPIP  The cause of FPIP is unknown, but does notThe cause of FPIP is unknown, but does not involve IgE, so all tests for allergy are usuallyinvolve IgE, so all tests for allergy are usually negativenegative  In most cases, avoidance of the offending foodIn most cases, avoidance of the offending food leads to a resolution of the problemleads to a resolution of the problem  When the baby is breast-fed, elimination of milkWhen the baby is breast-fed, elimination of milk and soy from the mother’s diet is usually enoughand soy from the mother’s diet is usually enough to resolve the infant’s symptomsto resolve the infant’s symptoms  Occasionally egg can cause the symptoms, inOccasionally egg can cause the symptoms, in which case, mother must avoid all sources of eggwhich case, mother must avoid all sources of egg in her diet as wellin her diet as well
  • 49 Progression of FPIPProgression of FPIP  In most cases, the disorder will resolve by theIn most cases, the disorder will resolve by the age of 1 or 2 yearsage of 1 or 2 years  After this age, the offending foods may beAfter this age, the offending foods may be reintroduced gradually, with carefulreintroduced gradually, with careful monitoring for the reappearance of blood inmonitoring for the reappearance of blood in the baby’s stoolthe baby’s stool
  • Elimination and Challenge Protocols
  • 51 Identification of Allergenic FoodsIdentification of Allergenic Foods  Removal of the suspect foods from theRemoval of the suspect foods from the diet, followed by reintroduction is thediet, followed by reintroduction is the only way to:only way to:  Identify the culprit food componentsIdentify the culprit food components  Confirm the accuracy of any allergyConfirm the accuracy of any allergy teststests  Long-term adherence to a restricted dietLong-term adherence to a restricted diet should notshould not be advocated without clearbe advocated without clear identification of the culprit foodidentification of the culprit food componentscomponents
  • 52 Food Intolerance: Clinical DiagnosisFood Intolerance: Clinical Diagnosis Symptoms Disappear Elimination Diet: Avoid Suspect Food Symptoms Persist Increase Restrictions Reintroduce Foods Sequentially or Double-blind Symptoms Provoked No Symptoms Diagnosis Confirmed Diagnosis Not Confirmed
  • 53 Elimination and ChallengeElimination and Challenge Stage 1Stage 1:: Exposure DiaryExposure Diary  Record each day, for a minimum of 5-7 days:Record each day, for a minimum of 5-7 days:  All foods, beverages, medications, and supplementsAll foods, beverages, medications, and supplements ingestedingested  Composition of compound dishes and drinks,Composition of compound dishes and drinks, including additives in manufactured foodsincluding additives in manufactured foods  Approximate quantities of eachApproximate quantities of each  The time of consumptionThe time of consumption
  • 54 Exposure Diary (continued)Exposure Diary (continued)  All symptoms graded on severity:All symptoms graded on severity:  1 (mild);1 (mild);  2 (mild-moderate)2 (mild-moderate)  3 (moderate)3 (moderate)  4 (severe)4 (severe)  Time of onsetTime of onset  How long they lastHow long they last  Record status on waking in the morning.Record status on waking in the morning.  Was sleep disturbed during the night, and if so,Was sleep disturbed during the night, and if so, was it due to specific symptoms?was it due to specific symptoms?
  • 55 Elimination DietElimination Diet Based onBased on::  Detailed medical historyDetailed medical history  Analysis ofAnalysis of Exposure DiaryExposure Diary  Any previous allergy testsAny previous allergy tests  Foods suspected by the patientFoods suspected by the patient  Formulate dietFormulate diet to exclude all suspect allergensto exclude all suspect allergens and intolerance triggersand intolerance triggers  ProvideProvide excluded nutrients from alternativeexcluded nutrients from alternative sourcessources  DurationDuration: Usually four weeks: Usually four weeks
  • 56 Selective Elimination DietsSelective Elimination Diets  Certain conditions tend to be associated with specific foodCertain conditions tend to be associated with specific food componentscomponents  Suspect food components are those that are probable triggersSuspect food components are those that are probable triggers or mediators of symptomsor mediators of symptoms  ExamplesExamples::  Eczema:Eczema: Highly allergenic foodsHighly allergenic foods  Migraine:Migraine: Biogenic aminesBiogenic amines  Urticaria/angioedema:Urticaria/angioedema: HistamineHistamine  Chronic diarrhea:Chronic diarrhea: Carbohydrates; DisaccharidesCarbohydrates; Disaccharides  Asthma:Asthma: Cyclo-oxygenase inhibitorsCyclo-oxygenase inhibitors SulphitesSulphites  Latex allergy:Latex allergy: Foods with structurallyFoods with structurally similar antigens to latexsimilar antigens to latex  Oral allergy syndrome:Oral allergy syndrome: Foods with structurallyFoods with structurally similar antigens to pollenssimilar antigens to pollens
  • 57 Few Foods Elimination DietFew Foods Elimination Diet  When it is difficult to determine which foodsWhen it is difficult to determine which foods are suspects a few foods elimination diet isare suspects a few foods elimination diet is followedfollowed  Limited to a very small number of foods andLimited to a very small number of foods and beveragesbeverages  Limited time: 10-14 days for an adultLimited time: 10-14 days for an adult  7 days maximum for a child7 days maximum for a child  If all else fails use elemental formulae:If all else fails use elemental formulae:  May use extensively hydrolysed formula for aMay use extensively hydrolysed formula for a young childyoung child
  • 58 Expected Results of Elimination DietExpected Results of Elimination Diet  Symptoms often worsen on days 2-4 ofSymptoms often worsen on days 2-4 of eliminationelimination  By day 5-7 symptomatic improvement isBy day 5-7 symptomatic improvement is experiencedexperienced  Symptoms disappear after 10-14 days ofSymptoms disappear after 10-14 days of exclusionexclusion
  • 59 ChallengeChallenge  Double-blind Placebo-controlled Food ChallengeDouble-blind Placebo-controlled Food Challenge (DBPCFC)(DBPCFC)  Lyophilized (freeze-dried) food is disguised inLyophilized (freeze-dried) food is disguised in gelatin capsulesgelatin capsules  Identical gelatin capsules contain a placeboIdentical gelatin capsules contain a placebo (glucose powder)(glucose powder)  Neither the patient nor the supervisor knows theNeither the patient nor the supervisor knows the identity of the contents of the capsulesidentity of the contents of the capsules  Positive test is when the food triggers symptomsPositive test is when the food triggers symptoms and the placebo does notand the placebo does not
  • 60 ChallengeChallenge (continued)(continued)  Drawback of DBPCFCDrawback of DBPCFC  Expensive in time and personnelExpensive in time and personnel  Capsule may not provide enough food toCapsule may not provide enough food to elicit a positive reactionelicit a positive reaction  Patient may be allergic to gelatin inPatient may be allergic to gelatin in capsulecapsule  May be other factors involved in elicitingMay be other factors involved in eliciting symptoms, e.g. taste and smellsymptoms, e.g. taste and smell
  • 61 ChallengeChallenge (continued)(continued)  Single-blind food challenge (SBFC)Single-blind food challenge (SBFC) Supervisor knows the identity of theSupervisor knows the identity of the food; patient does notfood; patient does not Food is disguised in a strong-tastingFood is disguised in a strong-tasting “inert” food tolerated by the patient:“inert” food tolerated by the patient:  lentil souplentil soup  apple sauceapple sauce  tomato saucetomato sauce
  • 62 Challenge PhaseChallenge Phase continuedcontinued  Open food challengeOpen food challenge  Sequential Incremental Dose Challenge (SIDC)Sequential Incremental Dose Challenge (SIDC)  Each food component is introduced separatelyEach food component is introduced separately  Starting with a small quantity and increasing theStarting with a small quantity and increasing the amount according to a specific scheduleamount according to a specific schedule  This is usually employed when the symptomsThis is usually employed when the symptoms are mild, and the patient has eaten the food inare mild, and the patient has eaten the food in the past without a severe reactionthe past without a severe reaction Any food suspected to cause a severe orAny food suspected to cause a severe or anaphylactic reaction should only be challenged inanaphylactic reaction should only be challenged in suitably equipped medical facilitysuitably equipped medical facility
  • 63 Open Food ChallengeOpen Food Challenge  Each food or food component is introducedEach food or food component is introduced individuallyindividually  The basic elimination diet, or therapeutic dietThe basic elimination diet, or therapeutic diet continues during this phasecontinues during this phase  If an adverse reaction to the test food occurs atIf an adverse reaction to the test food occurs at any time during the test STOP.any time during the test STOP.  Wait 48 hours after all symptoms haveWait 48 hours after all symptoms have subsided before testing another foodsubsided before testing another food
  • 64 Incremental Dose ChallengeIncremental Dose Challenge Day 1:Day 1: Consume test food between mealsConsume test food between meals  MorningMorning: Eat a small quantity of the test food: Eat a small quantity of the test food Wait four hours, monitoring for adverse reactionWait four hours, monitoring for adverse reaction If no symptoms:If no symptoms:  AfternoonAfternoon: Eat double the quantity of test food eaten in: Eat double the quantity of test food eaten in the morningthe morning Wait four hours, monitoring for adverse reactionWait four hours, monitoring for adverse reaction If no symptoms:If no symptoms:  EveningEvening: Eat double the quantity of test food eaten in: Eat double the quantity of test food eaten in the afternoonthe afternoon
  • 65 Incremental Dose ChallengeIncremental Dose Challenge (continued)(continued) Day 2:Day 2:  Do not eat any of the test foodDo not eat any of the test food  Continue to eat basic elimination dietContinue to eat basic elimination diet  Monitor for any adverse reactions during theMonitor for any adverse reactions during the night and day which may be due to a delayednight and day which may be due to a delayed reaction to the test foodreaction to the test food
  • 66 Day 3:Day 3:  If no adverse reactions experiencedIf no adverse reactions experienced  Proceed to testing a new food, starting Day 1Proceed to testing a new food, starting Day 1  If the results of Day 1 and/or Day 2 are unclear :If the results of Day 1 and/or Day 2 are unclear :  Repeat Day 1, using the same food, the same testRepeat Day 1, using the same food, the same test protocol, but larger doses of the test foodprotocol, but larger doses of the test food Day 4:Day 4:  Monitor for delayed reactions as on Day 2Monitor for delayed reactions as on Day 2 Incremental Dose Challenge (continued)
  • 67 Sequential Incremental Dose ChallengeSequential Incremental Dose Challenge  Continue testing in the same manner until allContinue testing in the same manner until all excluded foods, beverages, and additives haveexcluded foods, beverages, and additives have been testedbeen tested  For each food component, the first day is theFor each food component, the first day is the test day, and the second is a monitoring daytest day, and the second is a monitoring day for delayed reactionsfor delayed reactions
  • Maintenance DietMaintenance Diet
  • 69 Final DietFinal Diet  Must exclude all foods and additives to which aMust exclude all foods and additives to which a positive reaction has been recordedpositive reaction has been recorded  Must be nutritionally complete, providing allMust be nutritionally complete, providing all macro and micro-nutrients from non-allergenicmacro and micro-nutrients from non-allergenic sourcessources  There is no benefit from a rotation diet inThere is no benefit from a rotation diet in the management ofthe management of food allergyfood allergy  A rotation diet may be beneficial when theA rotation diet may be beneficial when the condition is due to dose-dependentcondition is due to dose-dependent foodfood intoleranceintolerance
  • 70 Minerals Milk Egg Peanut Tree Nuts Seeds Soy Fish Shell fish Wheat Corn Calcium + + + + + Phosphorus + + + + + + + + Iron + + + + + + + + Zinc + + + + + + + Magnesium + + + + + + Selenium + + + + + + + Potassium + + + + + Molybdenum + Chromium + + + Copper + + + + + Manganese + + + IMPORTANT NUTRIENTS IN COMMON ALLERGENS
  • 71 Vitamins Milk Egg Peanut Nuts Seeds Soy Fish Shellfish Wheat Corn A + + + + + Biotin + + + Folate + + + + + + Thiamin + + + + + + Riboflavin + + + + + + + Niacin + + + + + + + Pantothenic acid + + + + + B6 (Pyridoxine) + + + + + + + B12 + + + + D ++ ++ ++ ++ E + + ++ ++ ++ + K + + ++
  • 72 SummarySummary Food AllergyFood Allergy::  Immune system responseImmune system response Food Intolerance:Food Intolerance:  Usually metabolic dysfunctionUsually metabolic dysfunction Diagnostic Laboratory TestsDiagnostic Laboratory Tests::  Often ambiguous because different physiologicalOften ambiguous because different physiological mechanisms are involved in triggering symptomsmechanisms are involved in triggering symptoms
  • 73 SummarySummary Reliable testsReliable tests for the detection offor the detection of adverse reactions to foods:adverse reactions to foods:  Elimination and ChallengeElimination and Challenge Final dietFinal diet Must provide complete nutrition whileMust provide complete nutrition while avoiding all of the foods and foodavoiding all of the foods and food components that elicit symptoms oncomponents that elicit symptoms on challengechallenge