Signature Food Allergy Chart Made Easy

Signature food allergy chart

ooh dr. Rath dr. Nahar Korath who is with our allergy and immunology clinic who's going to give us a webinar today on food allergies fact and fiction dr. Rath thank you for that kind introduction thanks everyone for tuning in so today we're going to talk about a hot topic food allergies so we're gonna start with a case we'll come back to this at the end but it's just something to think about for now so out of these three cases which one do you think is most concerning for a true food allergy so the first one is a thirteen year old girl has bloating and cramping when she eats ice cream but she does fine with cheese and yogurt then we have a 65 year old man he has itching on his tongue whenever he eats raw bananas but he can do banana bread which is baked without any issues either and then we have a 30 year old man who gets hives on his chest and lip swelling whenever he eats anything containing peanuts so just some stuff to think about so some objectives for today I'm hoping that we'll be able to answer some of these questions and concerns that you all might have so defining what a food allergy is and then differentiating between a food allergy and a food intolerance also what food allergy testing involves and how we treat a reaction as well as what to do if you're worried about food allergies so if you'd allergy to start off with that's an immune system reaction usually it does not occur upon first exposure but it can and it's usually diagnosed in childhood but can be diagnosed at any age so the way this works is on the first exposure to a food that's an allergen antibodies form in your body and these allergy antibodies are called IgE antibodies on subsequent exposure so the next few times that you eat these cells that these IgE antibodies are attached to release histamine histamine is what causes symptoms of an allergic reaction and so food allergy reactions therefore like we had talked about don't usually occur on the first exposure because you have to develop those antibodies in order to react here's a little drawing of an allergen so let's say this is peanuts and what happens with the allergen specific IgE antibodies so in that first circle you see the allergen and then second circle you see the specific IgE for it that's what causes the release of all those sell mediators like histamine that leads to an allergic reaction so this can be a helpful little diagram to take a look at so what does a food allergy reaction look like it can be different for every person it also might not be the same reaction every time and usually it occurs within one to two hours of the same food exposure every time there are rare expect exceptions to this rule common symptoms of a food allergy reaction include hives swelling trouble breathing and sometimes GI symptoms associated with that like vomiting and diarrhea usually GI symptoms do not occur on their own in food allergy so allergenic metabolism of the foods occurs within one to two hours after eating and so delays of hours to days cannot be associated with that food that allergenic protein is already out of your system by then now anaphylaxis doesn't always occur due to a food allergy but this is the most common association that we see anaphylaxis with with an immediate prior trigger of a food anaphylaxis is generally known as two-plus body system involvement such as skin and GI system involvement or skin and respiratory system involvement so this is a life-threatening situation where you have to use your epi different auto injector which we talked about a little bit later and emergency care is needed so either calling 911 or going to the emergency room this is a great little diagram from kids with food allergies calm I'm sorry org and this is a good diagram of different things that people can associate with an impending allergic reaction so sometimes you feel like something Awful's going to happen having trouble breathing swelling of the lips etc and this is a good diagram what hives look like as well because I know that sometimes there's a question of what is hives and what is not hives so generally these look like big mosquito bites but they can look different on your skin depending on medications that you're taking pigmentation of your skin but these are general images of what it would look like these are the eight most common allergenic foods that we hear about so peanuts tree nuts milk eggs wheat soy fish and shellfish and these are probably the most common ones that you've heard about as well so when we're talking about food allergies this is under the umbrella of adverse food reactions it's under the immune-mediated category specifically IgE needed because that's that allergy antibody that we were talking about now pivoting to non immune mediated adverse food reactions that's when we're talking about food intolerances and we'll come back to this diagram as well so what's the difference between a food allergy and a food intolerance this is a big question so food allergy symptoms are potentially life-threatening and they're due to the protein product of the food and it's an immune system reaction so for example with a dairy or cow's milk allergy patients can't eat cheese yogurt any other type of milk products without a potential life-threatening reaction or some sort of a severe reaction people with food allergies are often able to identify this causative food because there's a pattern of these symptoms occurring every time they're exposed to it food intolerance --is also have a pattern but these are generally quite bothersome and irritating as opposed to life-threatening so for example headaches diarrhea vomiting and cramping and some food proteins can be tolerated in that group for example if you're lactose intolerant ice cream reiax worse in your body than certain cheeses do so you're able to eat some types of that protein product so food intolerance is a digestive system response it's specifically GI most of the time and usually it's an issue with the breakdown of the food so in people who have issues with digestion enzyme deficiencies sensitivity potentially to the food additives issues with naturally occurring chemicals and foods this is more commonly a food intolerance as opposed to a food allergy so this is a good chart to tell the difference between a food allergy and a food intolerance so on the left you have allergy symptoms on the right intolerance symptoms and then you do have some shared symptoms like we talked about with food allergy you can have gi associated symptoms but generally that's in association with your hives itching trouble breathing etc and so under allergy you can see that this is life-threatening and under intolerance it's not life-threatening the other thing is that with a food allergy reaction this is generally right after eating the food whereas an intolerance can present within hours eating the food it doesn't necessarily happen every time the food is eaten as well and you might need to eat a lot of it so you might be able to tolerate small amounts of the food which is not the case with a food allergy so pivoting to food intolerance or food sensitivity testing so this is not medically validated testing and it's marketed broadly without clinical relevance the antibody that they test for in these kits is the IgG antibody which is not associated with allergy or intolerance this antibody indicates exposure so that means that if you've ever eaten this food before in your life it might come back positive on the testing so this testing won't really give you answers about food intolerance but your symptoms do give a hint as to what might be triggering your symptoms so when it comes to the food intolerance or sensitivity testing the IgG antibody might actually be an indicator of tolerance to the food and not intolerance so again going back to the marketing of this as as your food making you sick or find out why you don't feel well this probably isn't going to be very helpful in the end and so documenting your symptoms is going to be the most important thing for you so this is an example of some sort of a result that you might get back as an IgG food allergy test which is how it's marketed as a food sensitivity your food allergy test so this is not something that we recommend it will not give you additional helpful answers and for food intolerance is the best treatment is a trial elimination of the bothersome foods so we were talking about dairy if you think that dairy is a trigger for you try going dairy free for two weeks to see if your stomach symptoms improve if you think that chocolate is a migraine trigger for you then avoid it for two weeks to assess if you have any changes so that's what we recommend primarily for food intolerance is another big question that we hear a lot is about the inheritance of food allergies so regarding family history food allergies are not inherited but a topic or allergic diseases such as eczema seasonal allergies asthma and food allergies they do have a hereditary link it's not a direct link though so if you and your partner have one of these allergic diseases and you have a child the child is then at a higher risk for having any of these atopic diseases but not one in particular so testing is not indicated for family members if they themselves have not had symptoms of food allergy so what looks like food allergy but maybe something else there are quite a few different things so episodes of random hives and swelling not always related to food allergy this can be a separate and chronic process GI symptoms like we talked about nausea vomiting diarrhea this is generally food intolerance if occurring in isolation and then you have symptoms of hay fever with itchy watery eyes congestion and runny nose so that's generally more associated with your environmental allergies and not foods but as a part of an anaphylactic reaction these symptoms can occur as well so to be associated with an allergic reaction there usually requires an immediate prior trigger so eating something within one to two hours of the reaction when we're talking about other things that look like food allergy but are not we're looking back at this chart again so F pies are food protein induced enterocolitis syndrome is under the immune-mediated category of adverse food reactions but it's not mediated by that allergy antibody we were talking about so this is something that's diagnosed in infants and toddlers most commonly and it's usually outgrown by the school-aged children so this is a great website about F pie so it's f pies org and so the symptoms of this are pretty classic with acute F pies you have repetitive vomiting diarrhea tiredness or lethargy dehydration hello blood pressure it's pretty significant symptoms of vomiting and diarrhea in chronic F pies you can have failure to gain appropriate weight in small children so that is something that is also seen and this is a good chart differentiating F pies and anaphylaxis so with F pies because of the type of reaction that it is skin and blood testing is not going to be helpful to food allergies because it's not mediated by that allergy antibody it can cause life-threatening shock and so those symptoms like we talked about throwing up stomach pain getting pale and very tired the most important treatment for this is fluid resuscitation are giving lots of fluids that sometimes required in the emergency room so this won't respond epinephrine auto-injectors like your anaphylaxis would so with f pies the most important thing is avoidance of the trigger food epinephrine auto-injectors like we talked about that's not going to help sometimes patients need IV fluids in the ER for this so the question is when can this food that trigger this reaction be eaten again well generally these reactions are in infancy or toddlerhood so it's recommended that an oral challenge is done years later and we'll talk about an oral challenge a little bit later but most of the time we recommend that these are done either in the hospital or at a university institution where there can be close observation in case the allergy I'm sorry the fbi's has not been outgrown because then if the patient is having vomiting diarrhea needs to go to the emergency room you have closer access for rehydration another thing that can look like a food allergy but isn't is something called pollen food syndrome or oral allergy syndrome and so this is associated with environmental or seasonal allergies so this occurs because there are cross reactive proteins in certain raw fruits vegetables and some nuts that cross react with environmental allergens so I'll show you a chart in a little bit that goes in detail about this this results in symptoms of oral itching tongue and throat burning or itching swelling of the lips pain in the mouth and similar symptoms of food allergies so it can be quite frightening the risk for anaphylaxis with this is pretty low in patients generally don't need epinephrine auto-injectors for this the difference between food allergy and pollen food syndrome or oral allergy syndrome is that once that raw fruit or vegetable product is baked it denatures that cross reactive protein so for example a patient with pollen food syndrome can't eat raw Apple but they can tolerate apple pie because that cross reaction is broken down by baking the Apple so this is a good chart that shows you some of the cross reactive proteins so for example if you're allergic to birch trees you might have issues tolerating your raw apples apricots cherries peaches and so on and then this is a little continuation so there's a lot of raw fruits and vegetables as well as some nuts that can be involved in this this is a good diagram about tips and treatments for people who have oral allergy syndrome or pollen food syndromes avoiding those raw foods that cross-react with your pollen allergens can be the most helpful or taking an oral antihistamine to relieve the mild symptoms baking or cooking those foods like we talked about to denature that protein or eating canned fruits or vegetables during the pollen season because the processing really helps break down that protein as well peeling the food can be helpful because a lot of that protein is in the peel or the rind of the fruit something else that can look like food allergy but is not a celiac disease which is a serious autoimmune disease involving gluten ingestion that leads to small intestinal damage so gluten is a protein that's found in wheat rye and barley and this is a hereditary disease generally that causes poor nutrient absorption and it causes significant GI symptoms so this can run a spectrum from bloating diarrhea constipation to weight loss and failure to gain appropriate weight and this is something that's managed by GI doctors and can be very severe this is not a food allergy though so there is an association between eczema and some food allergies because kids with eczema have a higher risk of food allergies but because of that sensitive skin barrier that patients with eczema have sometimes foods can cause rashes without a food allergy association and that's what we call contact dermatitis so if you have food concerns with your kid with eczema then you should talk to your allergist or your pediatrician to get a little bit more information because testing for food allergies can be pretty tricky in kids with eczema since they have a higher baseline level of the allergy antibody anyway so that can lead to difficult to interpret results so therefore your allergist might not want to test if the symptoms are not consistent with food allergy because we worry about false positive results that are going to mislead us so they might recommend a trial of dietary elimination instead going back to contact dermatitis so this can commonly occur in children with eczema and it's important to differentiate from food allergy it can occur in kids without eczema as well especially around the mouth in little babies where certain foods touch common foods to cause this issue our acidic foods so tomatoes or citrus fruits because food on the skin is irritating since it's not supposed to stay on there so what to expect at the allergist office when you go in for a food allergy visit the biggest thing is our discussion so a thorough clinical history is really important because we want to know the timeline we want to know when this happened what helped you as this happened before all the questions that can help us determine what we need to do next for you so if testing is indicated either skin or blood testing might be completed or both so skin testing involves pricks on the scan of the food extract that we're usually manufactured in a lab blood testing involves a blood draw for the specific concerning food allergens so your allergist might not test you if your symptoms are associated with food intolerance as opposed to food allergy if the reaction was recent we might have to wait a little bit to test you especially from the skin because you might have used up all of your allergy antibody and then we wouldn't get the appropriate result if antihistamines were taken within the prior week then we might defer the testing because you can get a false negative result sometimes blood testing can be sent instead but you should talk to your allergist about whether they want you to come back for skin testing or just send blood testing so this is a little picture of what some skin prick testing might look like the most common areas to do skin testing are on the back and upper arms some allergist also use the forearms and so it's either prick testing or scratch testing depending on the instruments used by your allergist so food panels are batches of testing usually for common food allergens like the 8 most common that we talked about before generally this is blood testing or specific IgE to foods we do not recommend sending food panels because of a high false positive rate and there's no added value to testing without a clinical history of food allergy because it can lead to misdiagnosis and misdirection so false positive results mean that about 50 to 60 percent of blood tests and skin tests to these food allergens can be false positives so the test shows up as positive even though you're not actually allergic to the food and this can occur because the test is measuring your response to the food protein that's undigested or it's detecting similar proteins among foods that don't trigger allergic reactions which is why allergies are very cautious about sending food testing positive testing without a prior history of food allergy reactions is called sensitization as opposed to allergy this is concerning for a false positive like we talked about and depending on what the clinical history is your allergist might recommend avoidance or an oral challenge and this is why like I said we don't recommend testing without symptoms because it can lead to a lot of unnecessary intervention out of concern for your safety for infants with moderate to severe eczema and/or egg allergy we might recommend peanut allergy testing prior to introduction of peanut because this is a common allergen in children with eczema and this would be one of the only times that testing would be done without a prior exposure to the food so this is our guideline that we follow for sending either blood testing or doing skin testing for a patient with eczema or egg allergy or both and then we determine whether peanut can be introduced based on those results so what is positive food allergy testing mean for skin testing we measure the size of the skin reaction where the allergen extract was applied and there's a cut-off size which indicates for us a positive reaction for blood testing depending on the food allergen we interpret the result but depending on the cutoff for that specific allergen so there's no one number that will tell us a significant answer a higher level does have higher clinical relevance but the level does not always associate with severity of the reaction so for example some patients can have really low levels on testing but have had a history of anaphylaxis to that food and some patients show false positive results with no history of reaction and continue to eat the food without a problem so if the clinical history was concerning for a food allergy and the testing was negative your allergist may recommend avoidance for a period of time with retesting or an oral challenge in the office so what do we do to treat or manage food allergies oral challenges are a mainstay of what we do and so we have you bring in a certain amount of that allergenic food that we're concerned that you've had a reaction to in the past and you ingest this over a period of time with a post observation period this is the only way for us to prove there's no allergy especially if there are concerns for false positive testing or inaccurate testing this is also how we test patients to see if they've outgrown a food out oh gee so when is this indicated these are recommended based on skin or blood testing or both for the allergenic food item based on our established cutoff values that we look at and we also look at your prior clinical history and deciding if this is an option so your allergist will talk to you about the risks and benefits before an oral challenge and if the numbers on the skin or blood testing or low or there's uncertain clinical history that might be why they're offering you an oral challenge to the food so an oral challenge appointment is a procedure appointment scheduled separately from an office visit this may be scheduled months out depending on your allergist scheduled and what their procedure days are and our ultimate goal is always safety we want to make sure there's proper staffing and supervision and no other health concerns so that we can keep an eye on you during the procedure so the risks and benefits of oral challenges the benefit is that we can tell you that you're no longer allergic to this or that you weren't allergic to it to begin with wrists are possible reactions so we can treat those in the office we would also potentially send you to the emergency room depending on the reaction but that's why we're very cautious and who we recommend oral challenges for and what we recommend oral challenges to a lot of allergist will not challenge infants or small children because it can be difficult to get them to eat a specific amount and difficult to gauge a reaction as well you should continue to avoid your food until you pass your oral challenge and continue to carry your epinephrine auto-injector like your allergist recommends even if your testing is negative the best method of ruling out of food allergy is with that supervise in office oral challenge if there's low suspicion of a food allergy and testing is not significant your allergist may offer an at-home introduction of the food but that depends on the allergist in the clinical history as well as the food so what are some other treatment and management options so long term studies are being conducted on oral immunotherapy or oral desensitization to peenie in particular and actually since I put these slides up a couple days ago there is now an fda-approved product for this peanut oral immunotherapy and this just came out I want to say two or three days it goes well I hadn't had a chance to update this but we're still gathering information on this and it's something that is an oral to induce tolerance overtime there are no allergy shots to treat food allergies these are considered dangerous because of the amount of food protein that a patient would be exposed to so short term for management definitely have a food plan avoid your food allergen carry an antihistamine with you something something like benadryl zyrtec or Allegra or any of those generic brands as well carry your epinephrine auto-injector and for children in school make sure the school nurse has an antihistamine and an epinephrine auto-injector available if your child cannot carry it or keep it on their person for someone with a food allergy epinephrine can be life-saving which we talked about a little bit later everyone in the house and everyone who takes care of that person should know how to use the auto-injector including daycare babysitter anybody else so an epinephrine auto-injectors should be prescribed and carried by all people with food allergies since the symptoms may not be the same every time in case of accidental exposure the worst case scenario is anaphylaxis and epinephrine is the only medication that can potentially prevent death if you soon enough of note patients with asthma are at higher risk of poor outcomes with food allergy related anaphylaxis so there are lots and lots of different types of epinephrine auto-injectors usually your insurance will determine which epinephrine auto-injector you're given EpiPen is the most common one that we hear about and many allergist will just say IV pen to refer to the general group of auto injectors there are pediatric doses which are smaller than adult doses for certain children's weights so these are just some pictures of what it might look like there are a bunch of different types so it's really important to know which one you have and how to use it so what are the side effects of epinephrine epinephrine is adrenaline so it'll cause jitteriness it can cause a fast heart rate but again this is the only life-saving medication in case of a severe reaction so we don't recommend delaying giving the medication due to concern for side effects because the goal of this is to jumpstart your circulatory system if you're using your EpiPen you should be calling 911 to the emergency room in an emergency situation an adult dose of epinephrine can be given to a child because there's far more risk with getting less epinephrine than needed and needing to repeat the dose than with giving an additional or higher dose so in the emergency room if you're having a food allergy reaction they might give you steroids they might give you a knee histamines sometimes a reflux medication like famotidine this also acts on the histamine receptors and can be part of a standard allergy cocktail that they would give you in the hospital and again they also might give you up in Efrain if they're concerned about anaphylaxis so a couple of final points so patients with egg allergies can receive the MMR vaccine without an issue the flu shot is also safe for patients with egg allergies because the flu shot is cultured in a chick embryo and there is not egg protein that remains with the flu shot some guidelines though still request that primary doctors refer patients to an allergist for evaluation before receiving the flu shot so if this is requested we'll usually provide the vaccine in clinic or do a challenge to the vaccine in clinic so we do hear a lot about shellfish allergy and concerns about iodine allergy iodine is naturally present in our bodies and in table salt it cannot be an allergen contrast media on the other hand can be an allergen but this is different from a reaction to iodine shellfish can contain iodine but that's not the allergenic part of shellfish because you're allergic to the protein in shellfish so people with shellfish allergies can receive iodine contrast unless they've had a prior contrast media reaction so some rare and controversial questions dye allergies are controversial there's no good testing that exists for them and anaphylaxis to dyes has been very rarely reported in scientific literature same with artificial coloring leading to behavioral changes in children controversial we don't have a whole lot of good evidence-based reports on this spice allergies when it comes to spicy foods in both heat and multiple spices combined this can have an irritant effect as opposed to an allergic effect such as frequent sneezing after inhaling black pepper or lips burning after red pepper or cayenne that's not necessarily a food allergy if you're worried about a food allergy then you should seek immediate medical help if you think you're having a reaction so don't seek don't delay seeking care especially if there's involvement of the respiratory system call 911 or go to the emergency room it's always better to be safe if you think seeing an allergist would help address some food allergy questions and you should talk to your primary care provider or call an allergist office to make an appointment so back to our initial question that we talked about so out of these three we'll go over the other two the one that's concerning for a food allergy is the thirty year old man who gets hives on his chest and lip swelling whenever he eats anything containing peanuts so for the thirteen year old girl so this is more lactose intolerance or food intolerance because she's able to eat cheese and yogurt without a problem but she only has bloating and cramping which are specifically GI issues when she eats ice cream so she doesn't have any whole body symptoms only GI symptoms and the 65 year old man he has itching on his tongue whenever he eats raw bananas but he can eat banana bread without any itching or additional symptoms so that's concerning for your pollen food syndrome or oral allergy syndrome because the cross reactive protein is in that raw fruit versus the environmental allergen and that's the issue that we see he can eat the baked form in banana bread because of that denatured protein so good resources obviously your primary care doctor is a great resource for you that your child's pediatrician they can refer you to an allergist as well if you're not sure where to go these are some good websites to go to as well that are validated and part of what we recommend if you have questions in addition those are some references that I used for this and that is the address for our Covington North Clinic and our rent and location for our Valley allergy and immunology clinics so thank you everybody and I'll take some questions yes I was diagnosed with food allergies last year and I thought there were just a few but he told me I was allergic to practically everything I ate so I have to take shots weekly is that unusual that's pretty unusual because shots don't exist for food allergies that we're aware of so I'm not entirely sure about that situation so we should we should chat after this yes I think so yes I have I have the same problem that that that girl had with the bloating and you know gasps and cramps right if I eat ice cream and milk products and I'd asked the doctor if I could just stop eating certain things that that would just kind of take care of all of this and he said well unfortunately someone else can but you can't you have to have you have to have shots for all of these things okay so I do eat those items but I still have some of the symptoms okay yeah so like we had talked about with the dietary elimination if you have issues with dairy then we do recommend trying to take that out of your diet for a little bit to see if your stomach feels better afterwards because that's a good way to test it out to see if that's what the intolerance is to if you don't notice any improvement in your symptoms after taking dairy out of your diet and after 2 weeks you can put it back in and see but that's the the trial is the best way to test for these food intolerances okay thank you very much welcome I have a question yeah if let's say like pineapple makes your tongue itchy or tingly is it still safe to eat other to eat pineapple if it gives you that reaction but it doesn't give you anything else it's you know you just get a little tingling and that's about it is it still safe to eat that food so if you're having tingling especially in the mouth with eating pineapple I would still recommend that you be seen by an allergist just to make sure that this isn't something that's more concerning for a food allergy because if it is oral allergy syndrome then that's something that is unlikely to progress to anaphylaxis for you to have an anaphylactic reaction but it's still possible and so if it's making you uncomfortable we recommend that you either don't eat it or you pretreat with an antihistamine beforehand but I always tell people to be very careful with it because your body is telling you that it doesn't like that raw fruit or vegetable I have a question I've heard that for some people who had an allergic reaction to bananas or other tropical fruit that they should avoid latex it because sometimes that will increase the chance that they'll have a latex allergy later can you tell us more about that so there is some cross reactivity and there's a question about how much of that is that oral allergy syndrome cross reactivity versus a risk for true anaphylaxis and so latex is not very commonly used anymore especially in the medical setting so latex allergies are not as commonly diagnosed but it's still something that can occur so if you have concerns that you're being exposed to latex that you're having a reaction to latex and you have an issue with banana or something like that then I would recommend that you talk to your primary care doctor talk to an allergist about whether it'll be beneficial to be tested for that thank you okay thank you dr. Rath you're welcome thanks everyone