Food%20allergy%20(pediatric) Treatment

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

Allergen Avoidance

• Considered 1st-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