Food allergy in children Allergic march Evolution of allergic diseases

forming and development of allergic diseases, beginning from early age: Allergic dermatitis Allergic rhinitis Allergic gastritis Bronchial asthma

The trigger factor of allergic diseases most frequently is food allergy.

Definition: Food allergy (FA) is a state of hypersensitivity to alimentary produces which is manifesting by appearance of clinical symptoms of diseases or allergic reactions.

There is a form of food intolerance. There is a form of adverse reaction to alimentary products. -published data often are not veridical. - FA: epidemiology -there are a different criteria of diagnosis. -the specific diagnostic methods are absent. Prevalence 5 6% of children; 3,7% of adults.

~ 11 millions of american people suffer by veridical FA. International studies in 6 regions constatated: 1 10% have allergy to eggs, peanuts, fruits, seafoods; 0,1 4,3% - to fruits; 0,1 1,4% - to legumes; 1% - to wheat, soya; ~ 1% of children from UK and USA have allergy to peanuts. In medium: milk 2,5%, eggs 1,3%, peanuts 0,8%, wheat 0,4%, soya 0,4%. FA: pathogenesis

Character multifactorial At the basis immunologic mechanism I. Immunologic phase II. Pathochemical phase III. Pathophysiological phase

4 types of immunopathological reactions: Reaction by I type (anaphylactic reaction, reagin dependent, immediate type hypersensitivity); Reaction by II type (cytotoxic type); Reaction by type III is characterising by forming of antigen antibody immune complexes , which are localizing at tissue level with inflammatory process appearance.

Reaction by IV type (cell mediated, late type) is producing by sensibilizyted T-lymphocytes which act through antibodies or complement cytotoxicity. The immune organs of digestive tract:

Specific lymphatic tissue, which regulates (through M-cells) the getting of antigens in the blood;

M-cells are sitting in Peyer patches together with B-lymphocytes, producing secretory IgA;

Diffuse lymphatic network covering GIT mucosa and containing B and T-cells.

Pathogenetic mechanisms: Antigens immunologic cells of digestive tract (mucosa, Peyer patches, lymphocytes, lymphatic noduls) cells lesionspecific antibodies forming immunopathologic reactions activation. AG + antibodies complex is fixing on the basophils surface releasing of active biologic factors. Mast cells, T-lymphocytes, neutrophils, epithelial cells; The level of mediators released from activated cells increases: histamin, active biologic substances, derivates of arahidonic acid, TNF, etc. These mediators initiate and maintain inflammatory chronic response to immune stimuls (allergens) and nonimmune. Classification of FA: IgE mediated FA

Diseases and typical allergic reactions

IgE nonmediated FA (with participation of another factors IgG, IgA, CIC, T-lymphocytes).

Allergic enterocolitis Allergic colitis Malabsorption syndrome (steatorrhea, diarrhea, physical retardation) provoked by FA (milk, egg, wheat flour, soya);

herpetiform dermatitis During hypersensitivity to gluten; Heiner syndrome (pulmonary hemosiderosis) sensitivety to cow,s milk; is associating with anemia, physical retardation, recidivant otitis, gastrointestinal symptoms. Factors contributing FA forming: Main: 1. Hereditary The clinical signs in children having allergic parents are more prononced. The concrete genes responsible for immune response (HLA system) were found 2. Secretory IgA deficiency 3. Increased permeability of digestive tract mucosae. Secondary: 1. Irrational alimentation of mother during pregnancy. 2. Dificult occurence of antenatal period. 3. Shortening of breast milk alimentation period (precocious introducing of complement) 4. Caesarian operation.

5. Disorders of alimentary products tolerance forming processes. 6. Disorders of newborn intestine colonization. Another favouring factors: Hygiene Changes in usual alimentation

Diversifying of alimentary products Fats abuse Produces having antioxidant peculiarities decresed rate Changes in the life style

Urbanization Smoking

Trigger factors Allergens Cow,s milk Eggs Peanuts Walnuts Fish Crustaceans (crawfish, lobster, shrimp, etc.) Soya Wheat

These 8 allergens provoke ~90% of allergic reactions associated with aliments. Another allergens: Chiken meat, Cow meat Croupes (oat, buckwheat, barley) Citric plants Vegetables (potatoes, cucumbers, tomatoes etc.) Fruits (orange apricots, peaches, mango etc.) Intersected allergy

Practically each alimentary product can be allergen. Clinical manifestations: Food allergy is characterized by response having inflammatory type: Local or Systemic

Evolution: Chronic or Acute, anaphylactic (including fulminant)

The polymorphism of clinical signs is characteristic for FA. Severity: from mild allergic reactions until severe allergic diseases and emergency states. Local clinical manifestations: can be involved any organ; more frequently: Skin: pruritis, different eruptions, eczema, urticaria, atopic dermatitis;

Gastrointestinal tract: vomiting, diarrhea, stomatitis, gastritis, gastroduodenitis, jejunitis, enteritis, colitis, meteorism, abdominal colics;

Allergic rhinitis; Allergic conjunctivitis; Bronhoconstriction: dyspnoea, wheesing, asthma; Ears: (otitis) pain, discomfort, hearing decreasing produced by inflammation and eustahian tube drainage function decreasing;

Headache.

Systemic clinical manifestations: Clinical signs appear rapidly after allergen intake Anaphylaxis Laringean edema Severe asthma Dermal reactions (toxico-allergic) Stivens-Johnson syndrome, Layel syndrome) Bronhoconstriction (status asthmaticus) Quinke edema Hypotension Coma Sudden death

Differential diagnosis: Alimentary intoxications:

They are provoked by direct action of alimentary product or added substances. It can be manifested by: Hyperemia of face, Nausea, Vomiting Diarrhea Headache Hypotension, collaps.

Food pseudoallergic, nonimmunologic (pharmacologic) reactions: They appear as a result of alimentary product or added substances direct action. For example: headache can appear after intake of chocolate or cheese, because every product contains pheniletilamine (vasoactive monoamine). Differential diagnosis: Allergic rhinitis and buccal cavity allergy. For example: allergy to ambrosia pollen is followed by pruritis or buccal cavity edema (lips, tongue, pharinx) after using in alimentation of watermelone, apples, carrots). The buccal cavity allergy can be also provoked by peaces, pears, potatoes. Eosinophilic gastroenteritis Characteristics: Peripheral eosinophilia Eosinophilic infiltrates situated in gastrointestinal tract.

Dispeptic syndromes (appear in affected segment): nausea, repeated vomiting, diarrhea (possible, with blood), enteropathy with protein loss, intestinal colics, increased body mass. Diagnosis: hemogram, esophago-gastro-duodeno-jejunoscopy, biopsy of mucosa. Specific diagnosis: 1. Allergologic anamnesis (ante-, postnatal); 2. Skin tests; 3. Elimination tests; 4. Alimentary diary; 5. Provocation tests (wery rare) 6. ELIZA (immunoenzymatic analysis) for specific IgE detection; 7. Reaction of hemagglutination; 8. Other investigations depending from clinical form and child,s age; Valence of sensibilization in food allergy Monosensibilization to alimentary allergens sensibilization to 1 produce; Polysensibilization sensibilization to more alimentary allergens; Polyvalent sensibilization allergy to more groups of allergens (foods, pollen, dust, drugs); The spectrum of sensibiliyation is recommended to be appreciated at least every 2 3 years. The stages of FA treatment: 1. The therapy of acute period Antihistaminic drugs

Corticosteroids 2. Induction of remission

Dietotherapy: specific, nonspecific Antiinflammatory drugs (chromones, corticosteroids) Symptomatic therapy Antileucotrienes 3. Therapy of exacerbation prevention

Dietotherapy Antiinflammatory drugs Correction of immunodefficiency Specific immunotherapy 4. Education

The treatment of anaphylactic reactions Epinephrine Antihistamines Provocative allergen elimination (the labels of alimentary produces, of sweets, that can contain nuts, must be studied). The produces, that can provoke intersected allergy, must be eliminated. PriPen (epinephrine). The school nurse must be instructed for emergency care according. The dietotherapy in FA Unique, universal diets, destined to the children with FA, in present not exist.

Every diet will be based on the anamnestic data and elimination provocation tests

Specific individual diets with elimination of founded known allergens Nonspecific diets with elimination of produces having high sensibilization potential

To anticipate the alimentary allergens with the potential of intersected sensibilization: Hen and eggs (<5%) Cows milk and beef meat (10%) Cows milk and goat milk (>90%) Fish (>50%) Peanuts and other vegetables (<10%) Soya and other vegetables (<5%) Wheat flour and other graminaceae (25%) Walnuts and other kinds of nuts (>50%)

The peculiarities of diet in sucklings The breast feeding is the preferable alimentation in sucklings with FA The natural alimentation must be maintained as more possible (at least until 6 months of child`s age) In children until 1 year of life, indifferently from allergologic examination data, the cow`s milk must be excluded from alimentation rate, until 2 years -the hem eggs, until 3 years the nuts, fish, seafoods

The complement (weaning foods) will be included to children with FA only after 6 months (indifferently from clinical form and severity of disease evolution)

The elimination diet must correspond to age necessities in proteins, lipids and glucides.

From mother`s ratio must be excluded only the produces which create the hypersensibilization in children; concomitantly the produces with high IgE sensibilization potential will be reduced.

In the case of breast milk insufficiency the child will be fed supplimentarely with industrially prepared adapted milk formulas.

The algorhythm for artificial alimentation milk formula selection: The using of formulas prepared on the base of cow`s milk integral protein is not admitted. The substitution of cow`s milk with kefir or goat milk in children with hipersensibility to cow`s milk proteins is not permited. In the absence of allergy to cow`s milk the formulas prepared on the base of milk protein partial hydrolization will be used (NAN HA). In the case of cow`s milk sensibilization finding the formulas prepared on the base of milk protein high hydrolization will be used (ALFARE). Drug treatment of exacerbation period: Antihistaminic drugs Systemic corticoids Epinephrine (shock, anaphylaxis) 2-agonists with short action (in the crises of asthma)

The antihistaminic drugs by I generation (central and peripheral H1receptors blockers) Dimetinden (Fenistil) Mebhidrolin (Diazolin) Klemastin (Tavegil) Hifenadin (Fencarol) Clorpiramin (Suprastin) From 1 month From 6 months From 12 months From 12 months From 1 month

Nonsedative generation of antihistaminic drugs (peripheral H1-histaminic receptors blockers) Cetirizin (Zirtec) Loratadin (Claritin) Dezloratadin (Aerius) Ebastin (Kestin) Fexofenadin (Telfast) Levocetirizin (Xyzal) From 6 months From 12 months From 6 months From 12 months From 6 months From 2 years

SYSTEMIC CORTICOSTEROIDS are indicating in the hospital conditions, in the following cases: Every forms of atopic dermatitis, resistent to topic corticosteroid and antihistaminic treatment. Diffuse and generalised urticaria Status asthmaticus Anaphylactic shock A few severe concomitant allergic diseases

Parenteral administration, preference doses:

PREDNISOLON - 1-2 mg/kg in 24 hours DEXAMETHAZON 0,15 0,30 mg/kg in 24 hours HYDROCORTIZON 5 6 mg/kg in 24 hours

Treatment duration constitues in medium 3 5 days.

Antirecidivant (support) treatment Membranostabilizing drugs: Sodium chromoglicate (Nalcrom, Colimun) 100 mg x 4 times per day (20 mg/kg) Montelucast, Zafirlucast 4 mg x 1 time per day (6 months 6

years), 5 mg/day > 6 years Anti IgE Omalizumab - subcutaneous injections x 1 time in 2 4 weeks Vaccination of children with allergic diseases Vaccination is not performed in the following cases: Severe anaphylactic reactions to preceding vaccinations Severe food allergy to hen egg proteins(in the case of vaccination with vaccins prepared on the base of chiken embryo) With vaccins containing traces of aminoglicosides: presence of systemic severe reactions in anamnesis Hepatitis B vaccination: systemic severe reactions to yeast For live vaccins: immunosuppression, some forms of immunodefficiency. Vaccination of children with allergic diseases:

Respecting of hypoallergic alimentary regime with exclusion of products at which the child manifests allergic reactions, and of obligate allergens (chocolate, apples, nuts, bee honey, fish, citric plants, strawberry, raspberry etc.) one week until vaccination and two weeks after.

Supervision of the child during 40 min. After vaccination, because in this period the development of allergic reactions, including anaphylaxis, is possible.

Antenatal prophylaxis 1. In pregnant women suffering by allergic diseases 2. In mothers having relatives suffering by allergic diseases 3. In mothers not suffering by allergic diseases Postnatal prophylaxis In children with high risk of allergic pathology forming: A) Exclusively breast milk alimentation with condition to respect by mother of hypoallergic diet B) Introducing of supplement (weaning food) after 6 months C) Hypoallergic formulas on the base of proteins hydrolization Alfare Progestemil High degree of hydrolization: Nutrimigen Nutrilon pepti TSC

Prophylaxis of FA in the risk group

Exclusive breast feeding until 6 months If necessary to administer hypoallergic (hydrolizated) formulas Introducing of complement after 6 months age Interdiction of smoking by mother Introduction in alimentation of gamma-3, gamma-6 unsaturated acids

External factors control

Excluding of tobacco smoke action Reducing of exposition to allergens in the building Reducing of pollutant factors action

Prognosis The degree of sensibility to allergens of cow`s milk soya, egg, wheat can decrease with the age: the tolerance can be set up. The allergy to nuts, fish, shrimps, lobster is more constant and the tolerance can`t set up easely.

Literature: 1. Arvola T, Moilanen E, Vuento R et al: Weaning to hypoallergenic formula improves gut barrier function to breast-fed infants with atopic eczema. J Pediatr Gastroenterol Nutr 2004; 38:92-96 2. Bischoff SC, Crowe S: Gastrointestinal food allergy: New insights into pathophysiology and clinical perspectives. Gastroenterol 2005; 128:1089-1113.

3. Markowitz JE, Spergel JM, Ruchelli E, et al: Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents. Am J Gastroenterol 2003;98:777-782. 4. Sampson HA: Update of food allergy. J Allergy Clin Immun 2004; 113:805-819. 5. Sampson HA: Utility of food-specific IgE concentrations in predicting symptomatic food allergy. J Allergy Clin Immunol 2001; 107:891-896. 6. Sicherer SH: Food allergy. Lancet 2002; 360:701-710.