Welcome! Check your audio connection to be sure your speakers are on and the volume is up. An On-Demand recording of this webinar will be available at: http://schoolnutrition.org/on-demand 1 SNA CEU will be available upon completion of a quiz. The quiz link will be emailed to you within 1 hour after the webinar concludes. @SchoolLunch facebook.com/SchoolNutritionAssociation
Today’s Moderators Sherry Coleman Toni Vega Aiken Collins, MS, RDN, LD Senior Manager of Registered Dietitian Professional Development National Peanut Board School Nutrition Association
FOOD ALLERGY Discussing the Science Behind the Facts
Affiliation or Financial Disclosure Sherry Coleman Collins, MS, RDN, LD Consultant – National Peanut Board • S Shahzad Mustafa, MD FAACT - Chairman, Medical Advisory Board •
Questions & Answers • 75 minutes • Q&A at the conclusion • Type your questions into the “Question” box at any time during the webinar • Questions will be addressed during the webinar and at the end as time allows
Earning CEUs • Complete Evaluation and Quiz • Print CEU at the end of the quiz. • The link is provided at the end of this webinar and emailed to you.
SNA CEUs & Professional Standards Key Area 1 (1000) Nutrition Key Topic: Subtopic (1100) Menu Planning (1160) Food Allergies
Handouts • Locate the Handout panel on your control panel. • Click on the name of the handout to download. • PDF of today’s slides • Food Allergy Resources Handout • Webinar Evaluation/Quiz Handout
LEARNING OBJECTIVES At the conclusion of today’s webinar, participants should be able to: • Explain the basics about food allergies, including signs and symptoms of a food allergy reaction and take steps to assist an allergic individual. • Discuss the impact of food allergies on quality of life for those with this condition. • Recommend and implement strategies to help improve the quality of life for those with food allergies.
Today’s Speaker S Shahzad Mustafa, MD Allergist / Clinical Immunologist Rochester Regional Health Clinical Assistant Professor of Medicine , University of Rochester
FOOD ALLERGY Discussing the Science Behind the Facts
My Two Hats
James Daly - Author “You cannot be distracted by the noise of misinformation.”
Definition of a Food Allergy • “An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a specific food.” Allergy Intolerance Requires sensitization Can occur in absence of sensitization Validated diagnostic testing Minimal validated diagnostic testing Reproducible reactions Reactions can occur inconsistently Dose independent Frequently dose dependent Caused by an individual allergen Can be caused by a class effect Cannot block with pre-treatment Validated pre-treatment regimens Desensitization protocols Desensitization not possible Can lead to death Typically very little mortality Boyce. JACI 2010; 126: 1105.
Common Food Allergens Pediatrics Adults Food % Food % Cow’s milk 2.5 Peanut 0.6 Egg white 1.5 Tree nuts 0.6 Peanut 1.0 Shellfish 2.0 Tree nuts 0.5 Finned fish 0.4 Wheat 0.4 Sesame 0.1* Soy 0.4 Shellfish 0.1 Finned fish 0.1 Sesame 0.1* Boyce. JACI 2010; 126: 1105.
Definition of Anaphylaxis • Acute, potentially life-threatening systemic/multi-organ reaction that is immunologically mediated and occurs after the likely exposure to an allergen • Clinical diagnosis • Very little if any role for acute diagnostic testing • Allergy/immunology referral recommended for long term management
Signs and Symptoms Common complaints NOT suggestive of an IgE mediated mechanism Isolated rhinitis Isolated cough/asthma Chronic abdominal discomfort Isolated GERD Chronic urticaria Fatigue Reactions occur inconsistently Reactions occur only with larger doses Ongoing mild to moderate atopic dermatitis
Time to Respiratory or Cardiac Arrest Pumphrey RS. Clin Esp All 2003; 30(8): 1144.
Management of Anaphylaxis • Epinephrine is the 1 st line and only FDA approved therapy • Antihistamines act as an adjunctive therapy mostly aimed at skin symptoms • Systemic steroids decrease the risk of biphasic or protracted reactions
Mediators of Anaphylaxis • Leukotrienes • Prostaglandins • Kinins • Platelet activating factor • Interleukins • Tumor necrosis factor • Histamine Benadryl (diphenhydramine)
Management of Anaphylaxis Epinephrine a 1 -adrenergic a 2 -adrenergic b 1 -adrenergic b 2 -adrenergic receptor receptor receptor receptor Vasoconstriction Insulin release Inotropy Bronchodilation Peripheral vascular Chronotropy Vasodilation Glycogenolysis resistance Mucosal edema Mediator release Simons. Curr Opin All Clin Immunol 2010; 10: 354.
Management of Anaphylaxis • Epinephrine • Antihistamines Simons. JACI 1998; 101: 33. Jones. Ann All Asth Immunol 2008; 100(5): 458.
Epinephrine Auto-Injectors
Poll Question Does your school maintain “stock epinephrine” to treat food allergy reactions?
Quality of Life with Food Allergy • 70% reported significant effects on social events • 60% reported significant effects on meal preparation • 40% reported a significant increase in overall stress levels • 34% reported an effect on school attendance • 10% chose to home school their children • Although other allergic conditions also have implications on quality of life, the addition of asthma and/or additional atopic conditions did not change these activity scores Bollinger. Annals All Asthma Imunol 2006. 96: 415., Springston. Ann All Asthma Immunol 2010. 105: 287
Mortality Associated with Food Allergy Umasunthar. Clin Exp All 2013; 43: 1333.
Impact on Parents Springston. Ann All Asthma Immunol 2010. 105: 287.
QOL with Peanut Allergy Versus Diabetes • 20 children with peanut allergy, 20 children with diabetes • Ages 7-12 Avery. Ped All Immunol 2003; 14:378.
Differences in QOL • Self-reported allergy versus patients followed at a food allergy referral center Ward. JACI IP 2016; 4: 257.
Differences in QOL Ward. JACI IP 2016; 4: 257.
Differences in QOL Based on Food Ward. JACI IP 2016; 4: 257.
Goldilocks Principle • “Relaxed readiness” – optimal level of anxiety that facilitates adaptive coping and effective disease management while minimizing maladaptive hypervigilance and potentially dangerous risk taking behavior
Over-Diagnosis of Food Allergy Fleischer. J Peds 2011; 158(4): 578.
Diagnostic Tools • Skin prick testing and in vitro immunoassays indicate the presence of Skin IgE antibody Prick • Skin prick testing and in vitro Test immunoassays do NOT prove clinical Immunoassay Detailed reactivity Oral Food Clinical Oral Food Challenge History • Food allergy requires the presence of IgE Challenge antibody AND clinical reactivity • Upwards of 50-60% of individuals have presence of IgE in the absence of clinical reactivity Celik-Bilgli. Clin Exp All 2005; 35(3): 268.
Oral Food Challenges • Performed to confirm or refute IgE mediated food allergy or to evaluate resolution of IgE mediated food allergy Total Challenges 701 Failed challenges 132 (18.8%) Reactions limited to skin symptoms 75 (10.7%) Reactions requiring epinephrine 12 (1.7%) Reactions requiring 2+ doses of epinephrine 1 (0.14%) Reactions requiring treatment in ED 1 (0.14%) Lieberman J. JACI 2011; 128(5); 1120.
Oral Food Challenges and QOL Franxman. JACI IP 2015; 3: 50.
Food Pollen Syndrome • Presents with oropharyngeal itching and discomfort typically with fresh fruits and vegetables in individuals allergic to environmental allergens
Airborne Peanut Allergen • Participants consumed peanuts to simulate various conditions • Cafeteria setting • Sporting event • Commercial airliner • Participants measured airborne protein via personal air monitors during the eating sessions with room ventilation turned off Perry. JACI 2004; 113(5): 973.
Rick of Airborne & Contact Exposure to Peanut Simonte. JACI 2003; 112(1): 180.
Poll Question What are the routes that can cause anaphylactic reactions to food?
Patient Views on Precautionary Labeling Hefle. JACI 2007; 120(1): 171.
Provider Views on Precautionary Labeling Turner. JACI IP 2016; 4: 165.
Provider Views on Precautionary Labeling Turner. JACI IP 2016; 4: 165.
Precautionary Labeling Percentage of Products with Detectable Allergen Hefle. JACI 2007; 120(1): 171.
Poll Question How confident do you feel reading labels with regard to food allergy management?
Food Allergy Guidelines Boyce. JACI 2010; 126(6): S1.
Special Considerations • Cow’s milk allergy • Roughly 70% will tolerate baked milk products • Alternatives include soy milk, coconut milk, almond milk, rice milk • Cannot safely consume goat’s milk • Egg allergy • Roughly 70% will tolerate baked egg products • Safe to administer influenza and MMR vaccines • Shellfish and finned fish allergy • Safe to receive contrast for radiographic studies • Systemic reactions with airborne exposure have been reported
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