Food allergy management and prevention

Overview & Definition

A four-year-old with egg allergy develops lip swelling and wheeze within minutes of a birthday cake. The two questions that follow define this topic: what do you do now, and what should you have done earlier to stop this child becoming allergic in the first place. Holding both answers at once is the fellowship skill. [5] [6]

A food allergy is an adverse immune-mediated reaction to a food protein. It is reproducible and immune-driven, which separates it from food intolerance (a non-immune mechanism such as lactase deficiency) and from simple food aversion. [5]

The mechanism matters because it changes everything that follows. IgE-mediated reactions are rapid, mast-cell driven, and can cause anaphylaxis within minutes. Non-IgE or mixed reactions are delayed, T-cell or eosinophil-driven, and are managed with diet rather than adrenaline. [6]

The single most useful framing for this topic is the manage versus prevent split. Management treats a child who already reacts. Prevention stops the allergy forming at all. The strongest prevention signal in modern paediatrics is early, sustained allergen introduction, which overturned the old advice to delay solids. [1] [4] [13]

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1. [1]Du Toit G Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med, 2015.PMID 25705822
2. [2]Du Toit G Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med, 2016.PMID 26942922
3. [3]Perkin MR Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. N Engl J Med, 2016.PMID 26943128
4. [4]Togias A Addendum guidelines for the prevention of peanut allergy in the United States: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol, 2017.PMID 28065278
5. [5]Boyce JA Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol, 2010.PMID 21134576
6. [6]Sicherer SH Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol, 2018.PMID 29157945
7. [7]Skripak JM The natural history of IgE-mediated cow's milk allergy. J Allergy Clin Immunol, 2007.PMID 17935766
8. [8]Ierodiakonou D Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune Disease: A Systematic Review and Meta-analysis. JAMA, 2016.PMID 27654604
9. [9]Natsume O Two-step egg introduction for prevention of egg allergy in high-risk infants with eczema (PETIT): a randomised, double-blind, placebo-controlled trial. Lancet, 2017.PMID 27939035
10. [10]Fleischer DM Consensus Communication on Early Peanut Introduction and Prevention of Peanut Allergy in High-Risk Infants. Pediatr Dermatol, 2016.PMID 26354148
11. [11]Obbagy JE Complementary feeding and food allergy, atopic dermatitis/eczema, asthma, and allergic rhinitis: a systematic review. Am J Clin Nutr, 2019.PMID 30982864
12. [12]Peters RL Natural history of peanut allergy and predictors of resolution in the first 4 years of life: A population-based assessment. J Allergy Clin Immunol, 2015.PMID 25725989
13. [13]Halken S EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update). Pediatr Allergy Immunol, 2021.PMID 33710678
14. [14]Simons FE World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol, 2013.PMID 24008815