Beruflich Dokumente
Kultur Dokumente
Toxic Non-toxic
(Staphylococcal Poisoning)
Non-immunologic
Immunologic
(pharmacologic effect, metabolic disorder)
Bock SA
Pediatrics
1987;79:683-8
Pathogenesi
s
Host Environment
Gene Food allergens
Mucosal barrier
Oral tolerance
Pathogenesi
s
Mucus
M Enzymes
U Bile
salts
C Low pH
O sIgA
S Epithelium w/ tight
junction
A Trefoil factors
L
B
A NK cells
R Macrophage
R
PMN
I
E Serum IgG IgA
Lymphocytes
R
Pathogenesi
s
Host A
Pediatr Allergy Immunol 5:5-36,
1994
Pathogenesi
s
Oral tolerance
Host
Gene S
E
Environment
predisposition N
S Food allergens
Mucosal barrier I
T
breakdown I
Z
Failure to develop A
T
Oral tolerance
I
O
Food Allergy
Pathogenesi
s
Family history of atopy as risk
factor of atopy in the child
Family history of atopy Child risk of
atopy
Biparental (same 40-60%
allergy) 40-50
Sibling 20-40
Uniparental
Pathogenesi
s
Infants
Low basal acid output
Suboptimal enzymatic activity
Increase intestinal permeability
(tight junctions are less “tight”)
sIgA system is not fully mature till
4 yrs old
Oral tolerance cannot be induced
yet due to immature MALT
Pathogenesi
s
Cow milk
Casein α-caseins
β-casein
κ-casein
Whey β-Lactoglobulin
α-Lactalbumin
Pathogenesi
s
Major food allergens isolated
& characterized
Fish Parvalbumin
Shrimp Tropomyosin
Wheat α-Amylase inhibitor
Celery Pathogenesis related
protein
Potato Patatin
Carrots Pathogenesis related protein
Apple Pathogenesis related protein
Profilin
Clinical
Manifestations
IgE mediated
Cutaneous
Urticaria
Angioedema
Gastrointestinal
Oral allergy
syndrome
GI anaphylaxis
Respiratory
Rhinitis
Asthma
Systemic
Anaphylaxis
Clinical
Manifestations
Mixed
Gastrointestinal
Allergic
eosinophilic
esophagitis
Allergic
eosinophilic
gastroenteritis
Cutaneous
Atopic dermatitis
Respiratory
Asthma
Clinical
Manifestations
Non-IgE mediated
Gastrointestinal
Food-protein induced
enterocolitis
Food protein induced
proctatitis
Food- protein
induced enteropathy
Celiac disease
Cutaneous
Contact dermatitis
Dermatitis
herpetiformis
Respiratory
Food induced
pulmonary
Clinical
Manifestations
Presumed mechanisms in food
allergies
Immunologi IgE mediated Non-IgE Mixed
c Reaction mediated
Onset of Minutes to 24 to 72 hours Minutes to
symptoms few hours several hours
Usual Minutes to Several days Hours to days
duration few hours
Predominat Anaphylaxis Celiac disease AD
e Urticaria Protein Asthma
Angioedema induced Allergic
Rhinitis enteropathy eosinophilic
GI Heiner enterocolitis
anaphylaxis syndrome
Clinical
Manifestations
Angioedema
Urticaria
Clinical
Manifestations
Angioedema of the
lip
Clinical
Manifestations
Historical details to be
ascertained
Description of symptoms & signs
Timing from ingestion to onset of
symptoms
Whether the ingestion of suspected food
produced similar symptoms on other
occasions
Frequency with which reactions have
occurred
Time of most recent occurrence
Diagnosis
RASTs
Significant dermatographism
Severe skin disease with limited
skin surface areas for testing
Difficulty to discontinue
antihistamine
Suspected exquisite sensitivity to
certain foods
Diagnosis
Other tests
Atopy patch test
Basophil histamine release assays
Intestinal Mast cell histamine release
assays
Diagnosis
Elimination diets
Use alternate formula: soy, extensively
hydrolyzed milk formula, amino acid
formula
Eliminate specific foods or restrict to the
following diet:
Rice or corn
Fresh lamb, beef & pork
2-3 vegetables (except cabbage, beans, spinach,
tomato)
2-3 fruits (except citrus fruits)
Water (apple juice)
Salt, sugar, honey, olive oil, vegetable oil,
Diagnosis
Food challenges
Open food challenge
Single blind food challenge
DBPCFC
Gold standard test
Treatmen
t
STRICT ELIMINATION of the
offending allergen is the
only proven therapy
Treatmen
t
Food allergen avoidance
Avoid high risk situation (buffet)
Take note of hidden allergens
Treatmen
t
Treatmen
t
Treatmen
t
Accidental ingestion
Auto-injectable epinephrine
Diphenhydramine tablet or syrup
Written emergency plan describing
their allergy, their potential
symptoms, medications to be given
& emergency phone numbers to
call
Treatmen
t
Medications
H1 & H2 blockers
Corticosteroid
To reverse severe inflammatory
symptoms
Leukotriene inhibitors
(Montelukast), cromolyn Na
Treatmen
t
Future approaches to food
allergy:
Conventional IT
Probiotics
Traditional Chinese Medicine
Mutated allergens
Anti-IgE antibodies (TNX-901, omalizumab)
Immunostimulatory sequence (CpG motifs)
Peptides
Bacterial adjuvants
Prognosis
Natural history
Usually Usually not
“outgrown” “outgrown”
Cow’s milk Peanut
Egg Tree nut
Soy Fish
Shellfish
Prognosis
Host A
Pediatr Allergy Immunol 5:5-36,
1994
Food: Essential for life
Food: Major source of
pleasure
Epidemiolog
y
35% of children with moderate
to severe atopic dermatitis have
IgE mediated food allergy
Eigenmann PA, et al
Novembre E, de Martino M,
Vierucci A JACI 81: 1059, 1988
Pathogenesi
s
S. Cherer
JACI 2005
Taking antihistamine prior
to intake of offending food
Modify the milder symptoms
Minimal efficacy
Mask early cutaneous symptoms
but can not block systemic
symptoms
Prevention
AAP recommendations for high
risk infants & infants with cow
milk allergy
Cow milk allergy infants
Exclusive breastfeeding (maternal
restriction of cow milk, egg, fish,
peanuts & tree nuts) & if this is
unsuccessful,
Pediatrics 2000;106:346-
349
Prevention
AAP recommendations for high
risk infants & infants with cow
milk
Cowallergy
milk allergy infants
Alternative to breastfeeding
Extensively hydrolyzed milk
formula
Free amino acid based formula
Soy formula
Pediatrics 2000;106:346-
Prevention
AAP recommendations for high
risk infants & infants with cow
milk allergy
High risk infants
Exclusive breastfeeding (maternal
restriction of peanuts, tree nuts, egg,
cow milk & fish)
Hypoallergenic formula or partially
hydrolyzed formula
No solid foods till 6 months of age with
dairy products delayed until 1 year, eggs
until 2 years, peanut, nuts & fish until 3
years Pediatrics 2000;106:346-
349
Prevention
AAP recommendations for high risk
infants & infants with cow milk
allergy
No maternal dietary restrictions
during pregnancy are necessary
except peanuts
Breastfeeding mothers on restriction
diet should use supplement minerals
(calcium) & vitamins
Pediatrics 2000;106:346-
349
Food Allergy Reactions
Prick S.T.
+ -
Laboratory studies -
&/or endoscopy,
biopsy Strong hx of anaphylaxis? Open feeding
+ -
Elimination diet
Ssx improved?
* Up to 2 wks for IgE mediated rxs; up to 8 wks + -
for non-IgE-mediated food hypersensitivity.
(+) (-)
(+) Equivocal (-)
DBPCFC
Symptoms
Recurred?
(+) (-)
+ -
Add to diet
Algorithm Diagnosing Food Hypersensitivity.
Adopted from: Bock SA, Sampson, HA. Evaluation of Food Allergy. In Leung, DYM & Sampson, SA (ed).
Pediatric Allergy: Principles & Practice, 2003. Mosby.