adverse effect of foods
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Definition ,Types ,Features ,Presentations ,Diagnosis ,Treatment ,preventionTRANSCRIPT
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Adverse Reactions to Foods
Prof. Dr. Saad Saleh Al AniSenior Pediatric ConsultantHead of Pediatric Department Khorfakkan HospitalSharjah ,[email protected]
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Adverse reactions to foods consist of any untoward reaction following the ingestion of a food or food additiveDefinition
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Facts
•Like other atopic disorders, food allergies have increased over the past 3 decades primarily in “Westernized” countries
•It now affect an estimated 3.5% of the U.S. population
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Up to 6% of children experience food allergic reactions in the 1st 3 yr of life, including about: -2.5% with cow’s milk allergy -1.5% with egg allergy -1% with peanut allergy
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•Most children “outgrow” milk and egg allergies, with about 50% doing so within 3-5 yr.
•In contrast, about 80-90% of children with peanut, nut, or seafood allergy retain their allergy for life
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Etiology
Adverse Reactions to Foods are classically divided into :1.Food intolerances which are adverse physiologic responses2.Food hypersensitivities which include adverse immunologic
responses and allergies
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Classification
1.Food intolerances
a. Host Factors
1.Enzyme deficiencies
- Lactase (primary or secondary) - Fructase maturational delay)
2.Gastrointestinal disorders
- Inflammatory bowel disease- Irritable bowel syndrome
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3.Idiosyncratic reactions
-Caffeine in soft drinks (“hyperactivity”)
4.Psychologic
- Food phobias
5.Migraines (rare)
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b. Food Factors
1.Infectious organisms
- Escherichia coli- Staphylococcus aureus - Clostridium
2.Toxins- Histamine (scombroid poisoning) - Saxitoxin (shellfish)
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-Caffeine- Theobromine (chocolate, tea) - Tryptamine (tomatoes)- Tyramine (cheese)
3.Pharmacologic agents
4.Contaminants-Heavy metals- Pesticides-Antibiotics
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2.Food hypersensitivities
a. IgE-Mediated
1.Cutaneous- Urticaria- Angioedema- Morbilliform rashes- Flushing- Contact urticaria
2.Gastrointestinal- Oral allergy syndrome- Gastrointestinal anaphylaxis
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3. Respiratory-Acute rhinoconjunctivitis - Bronchospasm
4. Generalized- Anaphylactic shock- Exercise induced anaphylaxis
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b. Mixed IgE- and Cell-Mediated
1.Cutaneous
- Atopic dermatitis- Contact dermatitis
2.Gastrointestinal- Allergic eosinophilic esophagitis and gastroenteritis
3. Respiratory- Asthma
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c. Cell Mediated
1.Cutaneous- Contact dermatitis- Dermatitis herpetiformis
2.Gastrointestinal
- Food protein–induced: enterocolitis proctocolitis, and enteropathy syndromes-Celiac disease
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3. Respiratory
- Food-induced pulmonary hemosiderosis (Heiner syndrome)
d. Unclassified
-Cow’s milk–induced anemia
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Remember
Ingestion of food normally leads to oral tolerance, which is the induction of T-cell anergy and T regulatory cells that enable the systemic immune system to “ignore” the roughly 2% of antigenic protein normally entering the systemic circulation at each meal
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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In young infants, functional barriers and immunologic barriers are immature, allowing increased penetration of food antigens, and the gut associated lymphoid tissue (GALT) appears less capable of “tolerizing” than the mature system
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Pathogenesis
•Food intolerances are the result of a variety of mechanisms, including host and food factors
•Food hypersensitivities are predominantly due to IgE mediated and/or cell-mediated mechanisms
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www.cincinnatichildrens.org
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www.sciencedirect.com
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Food-specific IgE antibodies
Bind to Fcε receptors on:
Mast cells
Basophiles Macrophages
Dendritic cells
Mediators are released
Smooth muscle contraction
Mucus secretion
Symptoms of immediate hypersensitivity
Certain allergens
Vasodilatation
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Acute IgE-mediated reactions
Symptoms elicited during acute IgE-mediated reactions can affect the:
•Skin (Urticaria, Angioedema, Flushing)
•Gastrointestinal tract (Oral pruritus, Angioedema, Nausea, Abdominal pain, Vomiting, Diarrhea)
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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•Respiratory tract (Nasal congestion, Rhinorrhea, Nasal pruritus, Sneezing , Laryngeal edema, Dyspnea, Wheezing)
•Cardiovascular system (Dysrhythmias, Hypotension, Loss of consciousness
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•In the other major form of food hypersensitivities lymphocytes, primarily food allergen– specific T cells, secrete excessive amounts of various cytokines that lead to a “delayed,” more chronic inflammatory process affecting the:
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•Skin (pruritus , erythematous rash)
•Gastrointestinal tract (cachexia, early satiety abdominal pain, vomiting, diarrhea),
•Respiratory tract (food induced pulmonary hemosiderosis).
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Mixed IgE and cellular responses to food allergens
Can also lead to chronic disorderssuch as: - Atopic dermatitis - Asthma - Allergic eosinophilic gastroenteritis.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Clinical Manifestations
•From a clinical and diagnostic standpoint, it is most useful to subdivide food hypersensitivity disorders according to: - Predominant target organ - Immune mechanism
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•Gastrointestinal food allergies are often the 1st form of allergyto affect infants and young children and typically manifest as: - Irritability - Vomiting or “spitting-up,” - Diarrhea - Poor weight gain.I. Gastrointestinal
Manifestations
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1.Food protein–induced enterocolitis syndrome
□Typically manifests as :• Irritability and protracted vomiting and diarrhea →dehydration. • Vomiting generally occurs 1-3 hr after feeding• Continued exposure →: - Abdominal distention - Bloody diarrhea - Anemia - Failure to thrive
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□ Symptoms are most commonly provoked by: - Cow’s milk - Soy protein–based formulas
□ A similar enterocolitis syndrome occurs in older infants and children from: - Rice - Oat - Wheat - Nut - Peanut - Egg -Chicken - Turkey - Fish sensitivity.
□ Hypotension occurs in about 15% of cases after allergen ingestion
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2.Food protein-induced proctocolitis
□ Presents in the 1st few months of life as blood-streaked stools in otherwise healthy infants
□ About 60% of cases occur among breast-fed infants, with the remainder largely among infants fed cow’s milk or soy protein–based formula
□ Blood loss is typically modest but can occasionally produce anemia
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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3.Food protein–induced enteropathy •Occasionally :
Anemia, Edema, and Hypoproteinemia
occur
•Often manifests in the 1st several months of life as: - Diarrhea - Steatorrhea (not infrequent) - Poor weight gain
•Symptoms include : - Protracted diarrhea - Vomiting ( up to 65% of cases) - Failure to thrive - Abdominal distention - Early satiety - Malabsorption
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• Cow’s milk sensitivity is the most common cause of this food protein– induced enteropathy in young infants
•Food protein–induced enteropathy has also been associated with sensitivity to - Soy - Chicken - Egg - Rice - Wheat - Fish in older children.
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Celiac disease
• The most severe form of protein-induced enteropathy
•The full-blown form is characterized by: i. Extensive loss of absorptive villi ii. Hyperplasia of the crypts leading to: - Malabsorption - Chronic diarrhea - Steatorrhea - Abdominal distention - Flatulence -Weight loss or failure to thrive
•Occurs in 1 : 100-1 : 250 of the U.S. population, although it may be “silent” in many patients
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•Genetically susceptible individuals (HLA-DQ2 or DQ8) demonstrate a cell-mediated response to tissue transglutaminase (tTGase) deamidated gliadin, which is found in: - Wheat - Rye – Barley
•Oral ulcers and other extraintestinal symptoms secondary to malabsorption are not uncommon.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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4.Allergic eosinophilic esophagitis
•Of children <1 yr of age presenting with GER, 40% have cow’s milk–induced reflux
•May appear from infancy through adolescence, more frequently in boys.
•In young children , it is primarily cell mediated and manifests as: - Chronic gastroesophageal reflux (GER) - Intermittent emesis - Food refusal - Abdominal pain - Dysphagia – Irritability - Sleep disturbance -Failure to respond to conventional reflux medications
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5.Allergic eosinophilic gastroenteritis
•Occurs at any age and causes symptoms similar to those of esophagitis as well as prominent weight loss or failure to thrive, both of which are the hallmarks of this disorder.
•More than 50% of patients with this disorder are atopic, and food-induced IgE-mediated reactions have been implicated in a minority of patients.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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• Generalized edema secondary to hypoalbuminemia may occur in some infants with marked protein- losing enteropathy.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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6.Oral allergy syndrome (pollen-food syndrome)
•Is an IgE mediated hypersensitivity that occurs in many older children with birch pollen– and ragweed-induced allergic rhinitis.
•Symptoms are usually confined to the oropharynx and consist of the rapid onset of : - Oral pruritus - Tingling and angioedema of the lips, tongue, palate, and throat - Occasionally : * Sensation of pruritus in the ears * Tightness in the throat
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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• Symptoms are generally short lived and are caused by local mast cell activation by fresh fruit and vegetable proteins that cross react with: - Birch pollen ( Apple , Carrot, Potato, Celery, Hazel nuts, Kiwi) - Ragweed pollen (Banana, Melons such as watermelon and Cantaloupe)
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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7.Acute gastrointestinal allergy
Generally manifests as: - Acute abdominal pain - Vomiting that accompany IgE-mediated allergic symptoms in other target organs.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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II. Skin Manifestations
Cutaneous food allergies are also common in infants and young children.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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1.Atopic dermatitis •The younger the child and the more severe the eczema, the more likely food allergy is playing a pathogenic role in the disorder.
•Is a form of eczema that generally begins in early infancy and is characterized by : - Pruritus - Chronically relapsing course - Association with asthma and allergic rhinitis
•30% of children with moderate to severe atopic dermatitis have food allergies
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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2.Acute urticaria and angioedema
•Are among the most common symptoms of food allergic reactions
•The onset of symptoms may be very rapid, within minutes after ingestion of the responsible allergen
•Symptoms result from activation of IgE bearing mast cells by circulating food allergens that are absorbed and circulated rapidly throughout the body
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•Chronic urticaria and angioedema are rarely due to food allergies.
•Foods most commonly incriminated in children include : -Egg - Milk - Peanuts - Nuts
•Reactions to various seeds (Sesame, Poppy) and fruits (Kiwi) are becoming more common.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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III. Respiratory Manifestations
• Many studies show that nasal congestion in infants is rarely caused by milk allergy
•Respiratory food allergies are uncommon as isolated symptoms.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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1.Food-induced rhinoconjunctivitis
•Wheezing occurs in about 25% of IgE- mediated food allergic reactions, but only about 10% of asthmatic patients have food-induced respiratory symptoms.
•Symptoms typically accompany allergic symptoms in other target organs, such as skin, and consist of typical allergic rhinitis symptoms : -Periocular pruritus and tearing - Nasal congestion and pruritus - Sneezing - Rhinorrhea .
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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IV. Anaphylaxis
•Food allergic reactions are the single most common cause of anaphylaxis seen in hospital emergency departments
•In addition to the rapid onset of cutaneous, respiratory, and gastrointestinal symptoms, patients may demonstrate cardiovascular symptoms, including : -hypotension - vascular collapse - cardiac dysrhythmias which are presumably caused by massive mast cell– mediator release.
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Diagnosis
• Thorough medical history whether a patient’s symptomatology represents: - An adverse reaction - The adverse food reaction is: * Intolerance * Hypersensitivity reaction and whether it is likely to be: i. IgE-mediated ii. Cell-mediated response
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The following facts should be established: (1) The food suspected of provoking the reaction and the quantity ingested, (2) The interval between ingestion and the development of symptoms, (3) The types of symptoms elicited by the ingestion (4) Whether ingesting the suspected food produced similar symptoms on other occasions (5) Whether other inciting factors, such as exercise, are necessary, (6) The interval from the last reaction to the food
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•Prick skin tests and in vitro laboratory tests are useful for demonstrating IgE sensitization
•Many fruits and vegetables require testing with fresh produce because labile proteins are destroyed during commercial preparation
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•A negative skin test result virtually excludes an IgE-mediated form of food allergy
•Majority of children with positive skin test responses to a food do not react when the food is ingested, so more definitive tests, such as quantitative IgE tests or food elimination and challenge, are often necessary to establish a diagnosis of food allergy
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Picture •Serum food-specific IgE levels ≥15 kUA/L for milk (≥5 kUA /L for children ≤1 yr) ≥7 kUA /L for egg (≥2 kUA /L for children <3 yr) ≥14 kUA /L for peanut Are associated with a >95% likelihood of clinical reactivity to these foods in children with suspected reactivity
Cont.
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• There are no laboratory studies to help identify foods responsible for cell-mediated reactions.
•Elimination diets followed by food challenges are the only way to establish the diagnosis
Cont.
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Picture • Before a food challenge is initiated, the suspected food should be eliminated from the diet for: - 10-14 days for IgE-mediated food allergy - up to 8 wk for some cell mediated disorders, such as allergic eosinophilic esophagitis.
Cont.
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Treatment
•Complete elimination of common foods (milk, egg, soy, wheat, rice, chicken, fish, peanut, nuts) is very difficult because of their widespread use in a variety of processed foods.
•Appropriate identification and elimination of foods responsible for food hypersensitivity reactions are the only validated treatments for food allergies
04/12/2023 Adverse reactions to foods Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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Picture •Children with: - Asthma and IgE-mediated food allergy - Peanut or nut allergy - History of a previous severe reaction should be given: * Self- injectable epinephrine (EpiPen) * Written emergency plan in case of accidental ingestion
Cont.
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• Many food allergies are outgrown • Reevaluation periodically is essential
• Other forms of therapy: -Anti-IgE immunoglobulin therapy -Engineered recombinant food protein vaccines -Herbal formulations.
•Tolerance may be generated by heating (cooking) the food (milk)
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Prevention
•Exclusive breast-feeding •Hydrolyzed milk-based formulas for the first 4-6 months of life may reduce allergic disorders
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References
1. http://www.foodallergy.org 2. Angier E, Sheikh A: Pollen food syndrome in a teenage
student. BMJ 2010; 340:b34053. Boyce JA, Assa'ad A, Burks AW, et al: Guideline for the diagnosis and
management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126(6):S1-S58
4. Lack G: Epidemiological risk factors for food allergy. J Allergy Clin Immunol 2008; 121:1331-1336
5. Pratt CA, Demain JG, Rathkopg MM: Food allergy and eosinophilic gastrointestinal disorders: guiding our diagnosis and treatment. Curr Prob Pediatr Adolesc Health Care 2008; 38:165-196.
6. Sackeyflo A, Senthinathan A, Kandaswamy P, et al: Diagnosis and assessment of food allergy in children and young people: summary of NICE guidance. BMJ 2011; 342:544-546
7. http://www.expertconsultbook.com
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