UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of food allergy: Avoidance

Author
Scott H Sicherer, MD, FAAAAI
Section Editor
Robert A Wood, MD
Deputy Editor
Elizabeth TePas, MD, MS

INTRODUCTION

The primary therapeutic strategy in the management of food allergy is avoidance of the culprit allergen. Complete avoidance is prescribed for immunoglobulin E (IgE)-mediated food allergies as well as food-protein enterocolitis in infants. (See "Food protein-induced proctocolitis of infancy".)

Successful allergen avoidance is straightforward in theory. However, in reality, avoidance requires extensive patient education. Clinicians should know how to instruct patients to read labels on packaged foods, prepare safe meals at home, and avoid food allergens in restaurant meals. Unintended exposure through cross-contact of foods in a variety of settings must be avoided. Food ingredients may be components of nonfood items, such as medications and vaccines. They may also be incorporated into substances that are inadvertently ingested, such as cosmetics and children's crafts. Lastly, exposure to allergen-containing saliva may occur during kissing or sharing of utensils. This topic review will present each of these issues individually.

The management of food allergy in daycare, schools, and camp settings is presented separately. (See "Food allergy in schools and camps".)

GENERAL CONSIDERATIONS

Patients with food allergy are typically instructed to practice strict avoidance. However, most patients attempting to eliminate a certain food from the diet will not be entirely successful, despite best efforts [1,2]. Thus, patients must be prepared to treat an unexpected reaction at all times and in any setting. A validated food allergy educational curriculum that describes specific food allergy disorders and addresses issues related to food allergen avoidance and use of self-injectable epinephrine is available for free at the Food Allergy Educational Program of the Consortium of Food Allergy Research [3].

How strict must avoidance be? — Strict avoidance is recommended for most patients with food allergy. However, thresholds of clinical reactivity vary dramatically among allergic individuals and can also vary depending upon how the food is processed. (See "Food allergens: Overview of clinical features and cross-reactivity" and "Pathogenesis of food allergy" and "Molecular features of food allergens".)

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Tue Jun 23 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Yu JW, Kagan R, Verreault N, et al. Accidental ingestions in children with peanut allergy. J Allergy Clin Immunol 2006; 118:466.
  2. Boyano-Martínez T, García-Ara C, Pedrosa M, et al. Accidental allergic reactions in children allergic to cow's milk proteins. J Allergy Clin Immunol 2009; 123:883.
  3. Sicherer SH, Vargas PA, Groetch ME, et al. Development and validation of educational materials for food allergy. J Pediatr 2012; 160:651.
  4. Taylor SL, Hefle SL, Bindslev-Jensen C, et al. Factors affecting the determination of threshold doses for allergenic foods: how much is too much? J Allergy Clin Immunol 2002; 109:24.
  5. Taylor SL, Hefle SL, Bindslev-Jensen C, et al. A consensus protocol for the determination of the threshold doses for allergenic foods: how much is too much? Clin Exp Allergy 2004; 34:689.
  6. Sicherer SH, Morrow EH, Sampson HA. Dose-response in double-blind, placebo-controlled oral food challenges in children with atopic dermatitis. J Allergy Clin Immunol 2000; 105:582.
  7. Flinterman AE, Pasmans SG, Hoekstra MO, et al. Determination of no-observed-adverse-effect levels and eliciting doses in a representative group of peanut-sensitized children. J Allergy Clin Immunol 2006; 117:448.
  8. Nowak-Wegrzyn A, Bloom KA, Sicherer SH, et al. Tolerance to extensively heated milk in children with cow's milk allergy. J Allergy Clin Immunol 2008; 122:342.
  9. Lemon-Mulé H, Sampson HA, Sicherer SH, et al. Immunologic changes in children with egg allergy ingesting extensively heated egg. J Allergy Clin Immunol 2008; 122:977.
  10. Ma S, Sicherer SH, Nowak-Wegrzyn A. A survey on the management of pollen-food allergy syndrome in allergy practices. J Allergy Clin Immunol 2003; 112:784.
  11. Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol 2003; 112:180.
  12. Roberts G, Golder N, Lack G. Bronchial challenges with aerosolized food in asthmatic, food-allergic children. Allergy 2002; 57:713.
  13. Wainstein BK, Kashef S, Ziegler M, et al. Frequency and significance of immediate contact reactions to peanut in peanut-sensitive children. Clin Exp Allergy 2007; 37:839.
  14. Young MC. Common beliefs about peanut allergies: Fact or fiction. Food Allergy News 2003; 12:1. The Food Allergy & Anaphylaxis Network. Fairfax, VA.
  15. Tonnel AB, Tillie-Leblond I, Botelho AD, et al. Severe acute asthma associated with raw meat cutting. Ann Allergy Asthma Immunol 2009; 102:348.
  16. Vadas P, Wai Y, Burks W, Perelman B. Detection of peanut allergens in breast milk of lactating women. JAMA 2001; 285:1746.
  17. Järvinen KM, Mäkinen-Kiljunen S, Suomalainen H. Cow's milk challenge through human milk evokes immune responses in infants with cow's milk allergy. J Pediatr 1999; 135:506.
  18. Lifschitz CH, Hawkins HK, Guerra C, Byrd N. Anaphylactic shock due to cow's milk protein hypersensitivity in a breast-fed infant. J Pediatr Gastroenterol Nutr 1988; 7:141.
  19. Monti G, Marinaro L, Libanore V, et al. Anaphylaxis due to fish hypersensitivity in an exclusively breastfed infant. Acta Paediatr 2006; 95:1514.
  20. Des Roches A, Paradis L, Singer S, Seidman E. An allergic reaction to peanut in an exclusively breastfed infant. Allergy 2005; 60:266.
  21. Isolauri E, Tahvanainen A, Peltola T, Arvola T. Breast-feeding of allergic infants. J Pediatr 1999; 134:27.
  22. Lake AM. Food-induced eosinophilic proctocolitis. J Pediatr Gastroenterol Nutr 2000; 30 Suppl:S58.
  23. Monti G, Castagno E, Liguori SA, et al. Food protein-induced enterocolitis syndrome by cow's milk proteins passed through breast milk. J Allergy Clin Immunol 2011; 127:679.
  24. Leonard SA, Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome: an update on natural history and review of management. Ann Allergy Asthma Immunol 2011; 107:95.
  25. Kim JS, Nowak-Węgrzyn A, Sicherer SH, et al. Dietary baked milk accelerates the resolution of cow's milk allergy in children. J Allergy Clin Immunol 2011; 128:125.
  26. Fiocchi A, Brozek J, Schünemann H, et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol 2010; 21 Suppl 21:1.
  27. Vandenplas Y, Koletzko S, Isolauri E, et al. Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child 2007; 92:902.
  28. Kemp AS, Hill DJ, Allen KJ, et al. Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Med J Aust 2008; 188:109.
  29. American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346.
  30. Høst A, Koletzko B, Dreborg S, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child 1999; 81:80.
  31. Lack G. Clinical practice. Food allergy. N Engl J Med 2008; 359:1252.
  32. Aldámiz-Echevarría L, Bilbao A, Andrade F, et al. Fatty acid deficiency profile in children with food allergy managed with elimination diets. Acta Paediatr 2008; 97:1572.
  33. Taylor SL, Hefle SL. Food allergen labeling in the USA and Europe. Curr Opin Allergy Clin Immunol 2006; 6:186.
  34. Center for Food Safety and Applied Nutrition. www.cfsan.fda.gov (Accessed on February 11, 2010).
  35. Simons E, Weiss CC, Furlong TJ, Sicherer SH. Impact of ingredient labeling practices on food allergic consumers. Ann Allergy Asthma Immunol 2005; 95:426.
  36. Warner JO. European Food Labelling Legislation--a nightmare for food manufacturers and allergy sufferers alike. Pediatr Allergy Immunol 2005; 16:1.
  37. Pieretti MM, Chung D, Pacenza R, et al. Audit of manufactured products: use of allergen advisory labels and identification of labeling ambiguities. J Allergy Clin Immunol 2009; 124:337.
  38. Hefle SL, Furlong TJ, Niemann L, et al. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007; 120:171.
  39. Noimark L, Gardner J, Warner JO. Parents' attitudes when purchasing products for children with nut allergy: a UK perspective. Pediatr Allergy Immunol 2009; 20:500.
  40. Jones RT, Squillace DL, Yunginger JW. Anaphylaxis in a milk-allergic child after ingestion of milk-contaminated kosher-pareve-labeled "dairy-free" dessert. Ann Allergy 1992; 68:223.
  41. Crotty MP, Taylor SL. Risks associated with foods having advisory milk labeling. J Allergy Clin Immunol 2010; 125:935.
  42. Ford LS, Taylor SL, Pacenza R, et al. Food allergen advisory labeling and product contamination with egg, milk, and peanut. J Allergy Clin Immunol 2010; 126:384.
  43. Sampson MA, Muñoz-Furlong A, Sicherer SH. Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol 2006; 117:1440.
  44. Kirschner S, Belloni B, Kugler C, et al. Allergenicity of wine containing processing aids: a double-blind, placebo-controlled food challenge. J Investig Allergol Clin Immunol 2009; 19:210.
  45. Rolland JM, Apostolou E, Deckert K, et al. Potential food allergens in wine: double-blind, placebo-controlled trial and basophil activation analysis. Nutrition 2006; 22:882.
  46. Sicherer SH, Furlong TJ, Muñoz-Furlong A, et al. A voluntary registry for peanut and tree nut allergy: characteristics of the first 5149 registrants. J Allergy Clin Immunol 2001; 108:128.
  47. Perry TT, Conover-Walker MK, Pomés A, et al. Distribution of peanut allergen in the environment. J Allergy Clin Immunol 2004; 113:973.
  48. Furlong TJ, DeSimone J, Sicherer SH. Peanut and tree nut allergic reactions in restaurants and other food establishments. J Allergy Clin Immunol 2001; 108:867.
  49. Ahuja R, Sicherer SH. Food-allergy management from the perspective of restaurant and food establishment personnel. Ann Allergy Asthma Immunol 2007; 98:344.
  50. Bailey S, Albardiaz R, Frew AJ, Smith H. Restaurant staff's knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy 2011; 41:713.
  51. Sicherer SH, Furlong TJ, DeSimone J, Sampson HA. Self-reported allergic reactions to peanut on commercial airliners. J Allergy Clin Immunol 1999; 104:186.
  52. Comstock SS, DeMera R, Vega LC, et al. Allergic reactions to peanuts, tree nuts, and seeds aboard commercial airliners. Ann Allergy Asthma Immunol 2008; 101:51.
  53. Greenhawt MJ, McMorris MS, Furlong TJ. Self-reported allergic reactions to peanut and tree nuts occurring on commercial airlines. J Allergy Clin Immunol 2009; 124:598.
  54. Greenhawt M, MacGillivray F, Batty G, et al. International study of risk-mitigating factors and in-flight allergic reactions to peanut and tree nut. J Allergy Clin Immunol Pract 2013; 1:186.
  55. Kelso JM. Potential food allergens in medications. J Allergy Clin Immunol 2014; 133:1509.
  56. Nowak-Wegrzyn A, Shapiro GG, Beyer K, et al. Contamination of dry powder inhalers for asthma with milk proteins containing lactose. J Allergy Clin Immunol 2004; 113:558.
  57. Savvatianos S, Giavi S, Stefanaki E, et al. Cow's milk allergy as a cause of anaphylaxis to systemic corticosteroids. Allergy 2011; 66:983.
  58. Levy Y, Segal N, Nahum A, et al. Hypersensitivity to methylprednisolone sodium succinate in children with milk allergy. J Allergy Clin Immunol Pract 2014; 2:471.
  59. Gu X, Beardslee T, Zeece M, et al. Identification of IgE-binding proteins in soy lecithin. Int Arch Allergy Immunol 2001; 126:218.
  60. Palm M, Moneret-Vautrin DA, Kanny G, et al. Food allergy to egg and soy lecithins. Allergy 1999; 54:1116.
  61. Awazuhara H, Kawai H, Baba M, et al. Antigenicity of the proteins in soy lecithin and soy oil in soybean allergy. Clin Exp Allergy 1998; 28:1559.
  62. Bernhisel-Broadbent J, Taylor S, Sampson HA. Cross-allergenicity in the legume botanical family in children with food hypersensitivity. II. Laboratory correlates. J Allergy Clin Immunol 1989; 84:701.
  63. Ylitalo L, Mäkinen-Kiljunen S, Turjanmaa K, et al. Cow's milk casein, a hidden allergen in natural rubber latex gloves. J Allergy Clin Immunol 1999; 104:177.
  64. Artesani MC, Donnanno S, Cavagni G, et al. Egg sensitization caused by immediate hypersensitivity reaction to drug-containing lysozyme. Ann Allergy Asthma Immunol 2008; 101:105.
  65. Codreanu F, Morisset M, Cordebar V, et al. Risk of allergy to food proteins in topical medicinal agents and cosmetics. Eur Ann Allergy Clin Immunol 2006; 38:126.
  66. Wang J, Nowak-Wegrzyn A. Reactions of 2 young children with milk allergy after cutaneous exposure to milk-containing cosmetic products. Arch Pediatr Adolesc Med 2004; 158:1089.
  67. Larramendi CH, Marco FM, Llombart M, et al. Allergenicity of casein containing chalk in milk allergic schoolchildren. Ann Allergy Asthma Immunol 2013; 110:335.
  68. Hallett R, Haapanen LA, Teuber SS. Food allergies and kissing. N Engl J Med 2002; 346:1833.
  69. Eriksson NE, Möller C, Werner S, et al. The hazards of kissing when you are food allergic. A survey on the occurrence of kiss-induced allergic reactions among 1139 patients with self-reported food hypersensitivity. J Investig Allergol Clin Immunol 2003; 13:149.
  70. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. J Allergy Clin Immunol 2006; 118:719.
  71. Wüthrich B, Däscher M, Borelli S. Kiss-induced allergy to peanut. Allergy 2001; 56:913.
  72. Jacobs JF, Baumert JL, Brons PP, et al. Anaphylaxis from passive transfer of peanut allergen in a blood product. N Engl J Med 2011; 364:1981.