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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.

Today’s Moderators

Sherry Coleman Collins, MS, RDN, LD

Registered Dietitian National Peanut Board

Toni Vega Aiken

Senior Manager of Professional Development 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

• Complete Evaluation and Quiz
• Print CEU at the end of the

quiz.

• The link is provided at the end
• f this webinar and emailed to

you.

Earning CEUs

Key Area 1 (1000) Nutrition

Key Topic: (1100) Menu Planning Subtopic (1160) Food Allergies

SNA CEUs & Professional Standards

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.”

• Boyce. JACI 2010; 126: 1105.

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

Common Food Allergens

Pediatrics

Food % Cow’s milk 2.5 Egg white 1.5 Peanut 1.0 Tree nuts 0.5 Wheat 0.4 Soy 0.4 Shellfish 0.1 Finned fish 0.1 Sesame 0.1*

Adults

Food % Peanut 0.6 Tree nuts 0.6 Shellfish 2.0 Finned fish 0.4 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 1st 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

• Simons. Curr Opin All Clin Immunol 2010; 10: 354.

฀ Vasoconstriction ฀ Peripheral vascular resistance ฀ Mucosal edema ฀Insulin release ฀ Inotropy ฀ Chronotropy ฀ Bronchodilation ฀ Vasodilation ฀ Glycogenolysis ฀ Mediator release a1-adrenergic receptor a2-adrenergic receptor b1-adrenergic receptor b2-adrenergic receptor

Epinephrine

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 IgE antibody

• Skin prick testing and in vitro

immunoassays do NOT prove clinical reactivity

• Food allergy requires the presence of IgE

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 Challenge Detailed Clinical History Skin Prick Test Immunoassay Oral Food Challenge

Oral Food Challenges

• Performed to confirm or refute IgE mediated food allergy or to evaluate resolution
• f IgE mediated food allergy

Lieberman J. JACI 2011; 128(5); 1120. 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%)

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

Special Considerations (cont’d)

• Soy allergy
• Safe to consume soy lecithin
• Peanut allergy
• Minimal if any risk with airborne exposure
• 95%+ will tolerate other legumes
• Nearly all will tolerate highly refined peanut oil
• Tree nut allergy
• Nearly all will tolerate coconut and shea nut
• No cross reactivity with seeds
• Reasonable to avoid certain tree nuts but consume others

Prevention of Peanut Allergy in the US

• Tojias. JACI 2017; 139: 29.

High Risk Infants

• Tojias. JACI 2017; 139: 29.

Summary

• Management of food allergies involves minimizing risk of allergen exposure while

maintaining an acceptable quality of life

• Behaviors should ideally be based on scientific evidence
• Minimizing broad food elimination
• Risks associated with airborne and contact exposure
• Correct Interpretation of labeling
• Special considerations for individual foods
• Early introduction of peanut is likely to decrease prevalence of peanut allergy,

especially in high risk infants

Questions?

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