food%20allergy%20(pediatric)
FOOD ALLERGY (PEDIATRIC)
Food allergy is an adverse reaction due to a specific immune response occurring reproducibly upon exposure to certain foods. It occurs minutes to hours after food consumption.
Immunological mechanisms can be IgE mediated, non-IgE mediated or mixed IgE and non-IgE mediated.
It may be life-threatening and is the most common cause of anaphylaxis in children.
It should be differentiated from food intolerance in which adverse reactions from exposure to food arise from non-immunological mechanisms.

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 & tissue concentrations of Epinephrine compared to subcutaneous (SC) route
    • At least 2 auto-injections should be prescribed & 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 & fluid resuscitation
  • May be given every 5-15 minutes as needed to maintain blood pressure & 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 & IV fluids
  • Continuous monitoring of vital signs should be done

Glucagon

  • May be used for refractory hypotension & bradycardia in patients who are taking beta blockers since vasopressor effects of Epinephrine may be decreased in these patients

Antihistamines (H1 & H2-receptor antagonists)

  • Limited evidence to support their use in emergency treatment of anaphylaxis
  • Useful only for relief of urticaria & itching

Atropine

  • May be considered for patients w/ bradycardia

Please see Anaphylaxis Disease Management Chart for more details

Nonacute Food-induced Allergic Reactions 

Antihistamines (H1 & H2-receptor antagonists)

  • Remain the mainstay in managing symptoms of nonsevere food-induced allergic reactions
    • Used mainly for cutaneous reactions (eg itching & 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 health care professionals
  • Anti-inflammatory properties of corticosteroids provide benefit in allergic diseases
  • Help prevent recurrence of symptoms & biphasic or protracted reactions

Non-Pharmacological Therapy

Allergen Avoidance

  • Considered 1st-line treatment in patients w/ documented & confirmed food allergies
  • Patients should be advised regarding cross-reacting allergens in other foods, hidden food allergens (eg casein & whey for cow’s milk, ovalbumin for chicken’s egg) & 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 & development
  • Individuals w/o 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 &/or fetal nutrition, & lack of evidence to support its implementation
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