GOOD

AFTERNOON

LITERATURE
REVIEW

DIAGNOSIS AND
MANAGEMENT OF FOOD
ALLERGY
By
Luh Witari Indrayani

Scientific advisor
dr. Made Sudipta,Sp.T.H.T.K.L

INTRODUCTION

Food allergy :
Collection of symptoms that affect many organs
and body systems caused by food allergies.
A reaction to a food that is essentially a
hypersensitivity reaction type I (IgE-mediated),
a cell-mediated or both.
Food allergic reaction involves three main
components:
food allergens
immunoglobulin E (IgE)
mast cells and basophils.

Literature
review

INTRODUCTION

PREVALENCE
United States : 3.5-4%, 8% in children under 3 years, 6-8%
of school-age children, and 2.5% in adults.
The tendency of increase in the prevalence of food allergies over
5 years to reach 55% per year.
Symptoms and signs : varies depending on the organ affected,
for example in the digestive system, the respiratory system or
skin.

Literature
review

INTRODUCTION

Not all adverse reactions to food is a pure allergic

reactions but many physicians or the general public use
the term food allergy to all unwanted reaction from
food, either immunological or non-immunological.
All of adverse reactions to foods and food additives
approximately 20% due to food allergies.

Literature
review

History:
Hippocrates the father of
medicine was the first to describe
the food adverse reactions (adverse
food reaction) around more than
2000 years ago.

yh

Anaphylactic reaction to egg is first

described by Marcello Donati
in the XVI century.
Anaphylactic reaction to fish is first

Philipp Sachs.
At the beginning of XX
century several cases of

described by

children with eczematous rash

Literature
review

History :
In 1950 Loveless first perform
a blinded placebo-controlled
food challenges to establish
yh of food allergy
the diagnosis
In May 1976 first introduced
the
use
of
double-blind
placebo controlled oral food
challenges, a protocol that is
currently considered the gold
standard for diagnosis of food
allergies.

Literature
review
American Academy of Allergy and Immunology
and The National Institute of Allergy and Infections
Disease.

ADVERSE FOOD REACTIONS

TOXIC/FO
OD
POISONIN
G

NON TOXIC

IMUNOLOGIC
REACTION

Ig E

Non Ig E

NON IMUNOLOGIC
REACTION
PSYCHOGE
NIC

FOOD
INTOLERAN
CE

Literatur
e review

Food allergy aberrant immunological reactions

due to the entry of allergens into the body of the
mechanism of this reaction can be mediated by
IgE or non-IgE.
Food intolerance non-immunologic reaction
to food and is largely the cause of unwanted
reactions
Food poisoning occurs when foods containing
the toxin

Literatur
e review

Metabolic reactions to foods

the body can not adequately digest the substances
contained in foods

Food idiosyncrasy
Quantitative abnormal response to food
substances or adittional substances that differ in
their physiological and farmacologic effects.

< children
US: 2% with food allergy
UK: 1,4-1,8% experienced adverse food reaction and
0.01 to 0.23% of adults are afected by adverse
reactions to food additives
2% of the adult population in the Netherlands is
afected by adverse food reactions

2,5% newborn baby cows milk in the first year of life

US and UK: Hypersensitivity reaction to eggs occurs in
approximately 1.3% of children and peanut occurred in
0.5% of children
Pediatric
polyclinic
Cipto
Mangunkusumo
Hospital: 4,6% food allergy(1987-1996)

Adult

Children

EPIDEMIOL
OGY

literature
review

Food allergen :

Allergen class I glycoprotein with molecular weight

of 10-70 kilodalton, resistant to heat, acid and
proteolytic enzym.
Allergen class IIepitope which very unstable to
high temperature,resistant to degradable enzym,
difficult to isolate.
Cows milk : betalactoglobulin (BLG),alfalactalbumin
(ALA),bovinserumalbumin
(BSA),bovingammaglobulin(BGG)
Wheat : albumin,pseudoglobulin and euglobulin

literature
review

Allergens that have been identified in

some food.
Food product

Allergen

Milk

Casein, lactoglobulin,lactoalbumin

Egg

Ovalbumin, conalbumin,
lypoprotein

Peanut

Arachin, lectin-reactive
glycoprotein, peanut I, conarachi

Soybean

Glycinin

Fish oil

Allergen M

Green beans

Albumin

Rice

Globulin or glutelin

tomato

Glycoprotein

Literature review

Predisposing factors

allergy

Dietary
habits

Food
processi
ng

Physical
factor

Psychologic
al factor

Literature review

Phatogenesis of food allergy

Gastrointes
tinal
mucosal
barrier

Physicoche
mical

Celluler

Literature review

Phatogenesis of food allergy

IgE mediated allergy
1. Sensitization phase
Antigen
catched
by
B-limphocyte
progenitor
antibody-producing
cellsbreak the antigen peptide
fragments that bound selectively to the
major histocompatibility complex (MHC)
class II recognized by the T cell receptor
on CD4 + T helper cells.

Literature review

Phatogenesis of food allergy

IgE mediated allergy:

2. Elitization phase
On subsequent exposure to the agent who
has been sensitized, cells that binds to IgE
bound to each other by agentmast cell
produced
inflammatory
mediatorphysiologic
changesfast
allergic
reactionskin,respiratory,
gastrointestinal symptom.

Food allergy
manifestation

Gastrointestina
l

Nausea,vommiting,diarrhea
and abdominal pain

Skin

Urtikaria, pruritus,skin
rash,edema

Respir
a
tory

Sneezing, rhinorhea,shortness
of breath

Food allergy
manifestation

Anaphylactic
shock

Difficu
lt to
breat
h

Hypote
nsi

Loss of
conscio
usness

Deat
h

In vitro

examina
IgE examination
tion
Basofl histamine release assay/BHR)
Intestinal mast cell histamine release (IMCHR)

Skin prick test

Intradermal test
Patch test
Food challenge test

Family history
Feeding history
Signs and symptoms of food allergy in infancy to
the present conditions

In vivo
examin
ation

histo
ry

Food allergy
diagnostic

Food allergy
Fooddiagnostic
provocation
test
Open food
challenge

single blind
placebocontrolled food
challenge

double blind
placebocontrolled food
challenge

Food allergy
diagnostic

Open
food
challen
ge

The doctor or
the patient
realizes that
the patients
consume food
that is
suspected
content of the
tested foods
are not
disguised.

Open
food
challen
ge

The skin test

negative for
the suspected
food

A child with a
history of egg
allergy are
given a cooked
egg, increased
the dose every
30 minutes until
all the eggs are
presented
eaten

hallenge
Food allergy
diagnostic Single
Single
blind

blind
placebocontrolled
food
challenge

Doctor realized
what was eaten
by the patient
but the patient
didnt

The suspected
food is
disguised so
the patient
didnt know
the content of
the food they
consumed

placebofood
controlled
food
challenge

a child with a
history of egg
allergy is
given the egg
that have
been hidden
in other foods.

hallenge
Food allergy
diagnostic Double
Double

blind
placebo
controlled
food
challenge

Doctor and
patient do not
know what the
patient ate

The suspected
food was
disguised in
other food

blind
placebo
controlled
food
challenge

Gold
standard
The most
reliable
method
because it
eliminates
bias in
doctor and
patient

Food provocation
test
Can not be

Can not be
done in patient
with a history of
apparent
allergic reaction

Elimination
diet at least in
2 weeks

Antihistamin
stopped at least
5 days in
advance

Patient should
be free of
symptoms and
fasting in the
day of testing

Intensive
medical
supervision

Food provocation
test

The suspected
food is disguised
in other food or
capsules

Test with the

other food can
be done on the
diferent days

Total dose : 8-10

gram dry food,
100 ml wet food,
two fold for meat
or fish

Divided into 7
doses :
1%,4%,10%,15%,2
0%,25% and 25%

Increased every
10-30 minutes and
wait for its
reaction 30
minutes after the
last dose is given

Literature
review
Managemen

t of food
allergy
Food
avoidan
ce

Eliminati
on diet

Auto
injector
device
containing
ephinefrin
e

Wear
medical
alert
bracelet or
necklace

Literature
review
Managemen

t of food
allergy
Meal plan or diet to eliminate
foods must be done carefully.
Any elimination diet should take into
account the individual's ability to
tolerate the offending food and the
need to avoid nutritional deficiencies.

Nutritionists assistance in
planning the diet and provide
alternative food or groceries.

Literature
review
Managemen

t of food
allergy
For successful elimination diet
notice food labels.
After conducting strict allergen-free
diet for 1-2 years one-third of
children and adult patients no
longer sensitive to food allergens
previously.

Literature
review
Managemen

t of food
allergy

Medical alert
bracelet

Auto-injector epinephrine
and how to use it

Literature
review
Managemen

t of food
allergy

Immunotherapy

For an individual against an

allergen desensitization pollen and
other environmental allergens.
It is not recommended to treat food
allergies dangerous because of
potential
serious
anaphylactic
reactions
The only way to prevent an allergic
reaction is to avoid the offending
food.

Gene therapy for peanut allergy is

now being done.

 0.61% of adults are allergic

to peanuts
0.09% of adults are allergic
to egg

Woods
et al

Indonesi
Prevalence of food allergy 5-11%
a
Allergy
Immunology
Clinic
Cipto
Mangunkusumo contained 4.6% of food
allergies during 1987-1996

Lovic

Lovic
Woman > Men
Eating habits infuenced k
bodys reaction

DISCUSSION

DISCUSSION

Davis et al:
USA0.6%
adults
allergic to
peanuts
Wilm et al:
Australia
allergic
chocolate as
much as
2%&0.1-0.28%
children have
allergy to
soybeans

Yoon et al:
3.7% adults
allergic to
corn
Allergy
Imonology
RSCM(2001):
10.3% children
allergy to
wheat& 8.8%
allergic to egg
yolks

Likura et
al:
JapanEgg is

the cause of
most food
allergies in
children amount
to 52.3%.

Sampson:

90% of food
allergies are
caused by an
allergy milk,
eggs, peanuts,
soybeans and
wheat

DISCUSSION

Sampson:
Adults85%
caused by
fish, peanuts
and shell

In a prospective study of
480 newborns who were
followed for 3 years
28% reported
experiencing adverse
reactions food was
mostly occurs in the first
year of life.
A quarter of the reported
reaction can be
confirmed by oral food
challenge.

As many as a third of cases

of anaphylactic shock
caused by food allergies.
An estimated 100 fatal
cases were caused by food
allergies occur each year in
the United States.

DISCUSSION

Bock et al.
Careful history-taking including the use of food
diaries by an experienced allergist can often
identify suspect foods.
Elimination diets followed by challenges can
sometimes confirm the existence of a foodassociated adverse reaction.
The gold standard for documenting existence
of a food allergy is double-blind placebocontrolled food challenge (DBPCFC)

DISCUSSION

Lemke and Taylor :

Prevalence IgE mediated food allergies likely
efect between 2 and 2.5% of the total
population

Bousquet et al and FAO :

Eight food or food groups are thought to account for
more than 90% of all IgE mediated food allergies in the
worldwide basis.
These foods are milk, eggs, fish (all spesies of finfish),
crustacea (shrimp, crab, lobster, crayfish), peanuts,
soybean, treenuts (walnut, hazelnut, pecans, cashew).

DISCUSSION
Zeiger and Heller :
The prevention of development of IgE
mediated food allergies among high-risk infant
has been along sought goal.
The result of several large clinical trial of highrisk infant followed for several years suggest
that the development of IgE mediated food
allergies can be delayed but not prevented
The maternal diet during pregnancy does not
seem to be a factor because sensitization does
not occur in utero.

o
DISCUSSION
Hattevig et al, Zeiger and
Heller :
The avoidance of commonly allergenics food in
the infant diet during the first few years of life
often delays the development of food allergies,
but food allergies still may develop after solid
food are introduced.

Kjellman and Bjorksten, Zeiger and

Heller :
Avoidance can be accomplished through breastfeeding for infants born to parents with histories
of IgE mediated allergies.

o
DISCUSSION
Sampson :
In a prospective study of 480 newborns who were followed
for 3 years as much as 28% reported experiencing adverse
food reactions was mostly occurs in the first year of life. A
quarter of the reported reaction can be confirmed by oral
food challenges.

As many as a third of cases of anaphylactic shock

caused by food allergies.
An estimated 100 fatal cases were caused by
food allergies occur each year in the United
States

CONCLUSIO
N allergy collection of symptoms that
Food
affect many organs and body systems caused by
food allergies are IgE-mediated reactions, cellmediated or both.

The etiology glycoprotein with a molecular

weight of 10 to 70 kilodalton and resistant to
heat , acids and proteolytic enzym.
Imaturitas or disorders of the gastrointestinal
barrier will lead the food allergens enter the
intestinal mucosa and activates the
immunological system response.

CONCLUSIO
N
The clinical symptoms of food allergy
reactionusually affecting the skin,
respiratory system and the gastrointestinal
tract.
Food allergy diagnosis on history, family
history, history of feeding, signs and symptoms
of food allergy in infancy until adolesence.
In vivo examination skin test and food
provocation test.

CONCLUSIO
N
In vitro examination examination of IgE,
monoclonal antibodies, histamine release by
basophils and mast cells release histamine by
intestinal.

Food provocation the gold standard for the

diagnosis of food allergy.
Proved efficient management is to avoid the

offending food

Thank you