Food%20allergy%20(pediatric) Treatment
Pharmacotherapy
Food-induced Anaphylaxis
Epinephrine
- In life-threatening anaphylaxis, self injectable intramuscular (IM) Epinephrine (0.01 mg/kg) is the only first-line of treatment; all other treatments are adjunctive
- IM route provides faster increase in plasma and tissue concentrations of Epinephrine compared to subcutaneous (SC) route
- At least 2 auto-injections should be prescribed and carried at all times by patients at risk for food-induced anaphylaxis
- Intravenous (IV) Epinephrine is recommended for patients who do not respond to repeated IM Epinephrine injections and fluid resuscitation
- May be given every 5-15 minutes as needed to maintain blood pressure and control symptoms
Bronchodilators (Inhaled)
- Eg Albuterol
- Adjunctive treatment for bronchospasm not responsive to IM Epinephrine
- Nebulized therapy, if available, is considered more practical than metered-dose inhalers
Vasopressors
- Eg Dopamine
- Used in cases of persistent hypotension in anaphylaxis despite administration of Epinephrine and IV fluids
- Continuous monitoring of vital signs should be done
Glucagon
- May be used for refractory hypotension and bradycardia in patients who are taking beta-blockers since vasopressor effects of Epinephrine may be decreased in these patients
Antihistamines (H1 and H2-receptor Antagonists)
- Limited evidence to support their use in emergency treatment of anaphylaxis
- Useful only for relief of urticaria and itching
Atropine
- May be considered for patients with bradycardia
Non-acute Food-induced Allergic Reactions
Antihistamines (H1 and H2-receptor Antagonists)
- Remain the mainstay in managing symptoms of non-severe food-induced allergic reactions
- Used mainly for cutaneous reactions (eg itching and urticaria) but not as first-line medication during anaphylaxis
- May also be used in cases where allergen avoidance is difficult or when it results in nutritional deficiencies
- Oral antihistamines used for first aid treatment of allergic reactions should be in chewable or liquid preparation to facilitate faster absorption
- Not recommended for prevention of food-induced allergic reaction
Corticosteroids
- Although not used in the treatment of acute anaphylaxis due to its slow onset of action, its empiric use is supported by healthcare professionals
- Anti-inflammatory properties of corticosteroids provide benefit in allergic diseases
- Help prevent recurrence of symptoms and biphasic or protracted reactions
Immunotherapy
- Treatment option for patients with confirmed IgE-mediated FA in whom avoidance measures are ineffective, not tolerated and affect patient’s quality of life
- Oral immunotherapy may be considered as a treatment option for children ≥4 years of age with clinically diagnosed persistent severe IgE-mediated cow’s milk protein allergy, hen’s egg allergy on the basis of increasing threshold for clinical reactions during treatment
- Peanut oral immunotherapy is recommended to select children ≥4 years of age with clinically diagnosed severe IgE-mediated peanut allergy under the supervision of a specialist to increase peanut tolerance during therapy
- Peanut epicutaneous immunotherapy may be considered in select children aged 4-11 years with clinically diagnosed severe IgE-mediated peanut allergy under the supervision of a specialist to increase peanut tolerance during therapy
- Clinical benefits should outweigh the side effects of oral, sublingual and epicutaneous immunotherapy, and the inconclusive evidence that they are able to induce long-term tolerance to the target foods should be considered
- Oral immunotherapy is more effective in inducing desensitization but may produce more adverse effects compared to sublingual and epicutaneous immunotherapy
- Indications for allergen immunotherapy (all of the following):
- History of IgE-mediated systemic allergic reactions after ingestion and/or positive oral food challenge
- Evidence of allergic sensitization
- Primary food allergy, as opposed to pollen food allergy syndrome due to cross-reactivity
- Persistent food allergy with low likelihood of spontaneous resolution
- Parents, patient and caregivers possess a full understanding of effectiveness, side effects, logistics and the potentially life-long duration of the therapy
- Parents, patient and caregivers should be motivated, adherent and capable of administering emergency treatment
- History of severe reactions to food or impaired quality of life due to burden of food allergy
- Willingness of parents, patient and caregivers to incorporate the food into diet
- Stability of living and family situation
- Absolute contraindications include poor adherence, uncontrolled/severe asthma, active malignancy, active systemic autoimmune disorders, systemic immunosuppression therapy, active eosinophilic esophagitis, other gastrointestinal eosinophilic disorders, pregnancy
- Relative contraindications include severe systemic illness, severe medical conditions eg cardiovascular diseases, systemic autoimmune disorders in remission, uncontrolled active atopic dermatitis, uncontrolled chronic urticaria, beta-blocker or ACE inhibitor therapy, mastocytosis, increased dose of other immunotherapy, chronic undiagnosed gastrointestinal symptoms, inability to ingest study products, psychological problems or possibility of eating disorders
Monoclonal Antibodies
- Eg Dupilumab, Omalizumab
- Omalizumab, a monoclonal anti-IgE antibody, has been granted breakthrough therapy designation by the United States Food and Drug Authority for the prevention of severe allergic reactions following accidental exposure to ≥1 foods in people with allergies
- Clinical trials showed that Omalizumab has the potential to induce desensitization in patients with food allergy
- Omalizumab may also be given as an adjunct to oral immunotherapy
- Studies showed that Dupilumab may reduce food allergy reactions by inhibiting IL-4 and IL-3 receptors that are associated with increased risk of food allergies
- Etokimab is undergoing clinical trials for its use in peanut allergy
Non-Pharmacological Therapy
Allergen Avoidance
- Considered first-line treatment in patients with documented and confirmed food allergies
- Patients should be advised regarding cross-reacting allergens in other foods, hidden food allergens (eg casein and whey for cow’s milk, ovalbumin for chicken’s egg) and high risk situations like anaphylaxis
- Elimination diet is advised only based on a positive history confirmed by skin prick test (SPT) or specific IgE test
- Ensure that nutritional requirements of patients are met to avoid nutritional deficiencies
- Ensure that the patient is clinically allergic to a particular food before removing it from their diet; may be pertinent to the patient’s growth and development
- Individuals without documented or confirmed food allergy (FA) are not recommended to avoid potentially allergenic foods as part of managing asthma, atopic dermatitis or eosinophilic esophagitis
- Allergen avoidance during pregnancy to prevent allergy in the offspring is not recommended due to risk in maternal and/or fetal nutrition, and lack of evidence to support its implementation