Food Allergy in Children

Sun-Hee Choi; Yeong-Ho Rha

doi:10.5124/jkma.2009.52.11.1090

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Choi and Rha: Food Allergy in Children

Continuing Education Column

J Korean Med Assoc 2009;52(11):1090-1099.

Published online: 10 January 2009

DOI: https://doi.org/10.5124/jkma.2009.52.11.1090

Food Allergy in Children

Sun-Hee Choi, MD, Yeong-Ho Rha, MD

Department of Pediatrics, Kyung Hee University College of Medicine E – mail: chsh0414@naver.com, yhrha@khmc.or.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Food allergy has increased in developed countries over the past 20 years and it has been estimated that food allergic reactions affect some 6∼8% of children. Food allergy is common and potentially serious problem in childhood. Adverse reaction to food could be classified into four groups: IgE-mediated food allergy; non-IgE mediated food allergy; non-allergic food hypersensitivity; and symptoms falsely assumed to be due to foods. Allergic testing is moving towards established thresholds levels of specific IgE that predict a probability of a clinical reaction and reduce the need of oral food challenge. Diagnosing and managing food allergy in children largely depends upon a thorough medical history with questions targeted to differentiate the character of the reaction for each suspected food. Investigations such as skin prick testing and specific IgE are helpful only in IgE-mediated reactions. The mainstay of management is to avoid the offending allergen. An anaphylactic reaction is an indication for self-injectable epinephrine for emergency use. Studies of allergen characterization and immunologic mechanisms are needed and should provide a better understanding of the immunopathology of food allergy and new, more specific forms of diagnosis and therapy. It is important to identify children with potentially life-threatening food allergy as life-threatening reaction can occur. A clear understanding of the manifestations of food allergy caused by both IgE- and non-IgE-related mechanisms will help the practitioner to identify children who likely have food allergy so that additional diagnostic evaluation can be performed and appropriate avoidance can be instituted.

Keywords: Food allergy, Children, Oral tolerance, Specific IgE assays, Elimination diet

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Figure 1.

Schematic approach to diagnosis and management of allergy (Modified from Med Clin N Am 2006; 90: 97–127).

Table 1.

Immunopathology and clinical manifestations of selected food allergic disorders

Immonopathology	Disorder	Key feature	Common trigger food
IgE antibody dependent (acute)	Urticaria/angioedema	Wheal, flare and edema within minute to 2h, after ingestion or by direct skin contact: food indentified as a culprit in 20%	Multiple foods
	Oral allergy syndrome (pollen-food related)	Immediate symptoms on contact of the raw fruit with oral mucosa: pruritis, tingling, erythema, angioedema of the lips, tongue, oropharynx, throat itching	Raw fruits/vegetables
	Anaphylaxis	GI symptoms in concert with cutaneous and /or respiratory manifestation with to 2h	Milk, egg, soy peanuts, tree nuts, shellfish, vegetables
	Food associated exercise-induced anaphylaxis	Food trigger anaphylaxis only if ingestion followed temporally by exercise	Wheat, shellfish, vegetables
	Rhinitis, asthma	These symptoms may accompany a food-allergic reaction but are rarely isolated or chronic symptoms
IgE antibody associated. cell mediated (delayed onset/chronic)	Atopic dermatitis	Associated with food in 35% of children with moderate to severe rash: Relapsing pruritic vesiculopapular rash	Milk, egg, wheat, soy
	Eosinophilic gastroenteritis	Symptoms dependent on site/degree of eosinophilic inflammation. Esophagus (eosinophilic esophagitis)-dysphagia, pain, GE reflux,. Genealized-failure to thrive, pain, emesis, protein losing enteropathy	Multiple foods,
Cell mediated (delayed onset/chronic)	Diatary protein proctocolitis	Mucus-laden, bloody stools in infants	Cow milk via breast feeding
	Diatary protein enterocolitis	Chronic emesis, diarrhea, failure to thrive	Cow milk, soy, grains

Modified from Med Clin N Am 2006; 90: 97–127.

Table 2.

History to be obtained for a subject reporting an adverse reaction

1. Description of symptoms and signs

2. Timing from ingestion to onset of symptoms

3. Frequency with which reactions have occurred

4. Time of most recent occurrence

5. Quantity of food required to evoke reaction

6. Associated factors (activity, medication)

Adopted from Leung DYM, et al.(eds). Pediatric allergy: Principle and Practice. 1st. ed. St. Louis: Mosby, 2003: 481

Table 3.

Adverse reactions to foods mimicking food allergy

Condition	Symptomatic Manifestation	Mechanism
Lactose intolerance	Bloating, Abdominal pain, diarrhea (dose dependent)	Lactase deficiency
Fructose intolerance	Bloating, Abdominal pain, diarrhea (dose dependent)	Fructase deficiency
Pancreatic insufficiency, Gallbladder/liver disease	Malabsorption	Deficiency of Enzyme
Food poisoning	Pain, fever, nausa, vomiting, diarrhea	bacterial toxin in food
Scombroid fish poisoning	Flushing, angioedema, abdominal pain	Histidine in spoiled fish metabolized histamine
Thyamine in aged cheese	Migraine	Pharmacologic effects of thyramine in susceptible individual
Caffeine	Tremor, cramps, diarrhea	Pharmacologic effects of thyramine in susceptible individual
Auriculo-temporal syndrome	Facial flush in trigeminal nerve distribution associated with spicy foods	neurogenic reflex, frequently associated with trauma to trigeminal nerve
Gustatory rhinitis	Profuse watery rhinorrhea associated with spicy food	Neurogenic reflex
Allergy to contaminants in foods	Wheal, pruritus, angioedema, coughing, vomitting	IgE- mediated reactions dust mites and molds contaminating flour, Anisakis parasite in fish

Modified from Med Clin N Am 2006; 90: 97–127.

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