Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel - 07/08/11

Doi : 10.1016/j.jaci.2010.10.007

NIAID-Sponsored Expert Panel

Abstract

Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.

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Key words : Food, allergy, anaphylaxis, diagnosis, disease management, guidelines

Abbreviations used : AAP, ACD, ACIP, AD, AP, APT, BP, CC, CDC, CI, CMA, COI, DBPCFC, DRACMA, EAACI, EG, EGID, eHF, eHF-C, eHF-W, EoE, EP, FA, FAAN, FALCPA, FPIES, GI, GINI, GRADE, ICD-9-CM, ICU, IM, IV, MDI, MMR, MMRV, NIAID, NICE, NSAID, OAS, pHF, pHF-W, PI, RCT, RR, SAFE, sIgE, SPT, WAO

Plan

Preface

Introduction

Overview

Relationship of the US Guidelines to other guidelines

How the Guidelines were developed

Defining the strength of each clinical guideline

Summary

Definitions, prevalence, and epidemiology of food allergy

Definitions

Prevalence and epidemiology of food allergy

Knowledge gaps

Natural history of food allergy and associated disorders

Natural history of food allergy in children

Natural history of levels of allergen-specific IgE to foods in children

Natural history of food allergy in adults

Natural history of conditions that coexist with food allergy

Asthma

Atopic dermatitis

Eosinophilic esophagitis

Exercise-induced anaphylaxis

Allergic rhinitis

Risk factors for the development of food allergy

Risk factors for severity of allergic reactions to foods

Incidence, prevalence, and consequences of unintentional exposure to food allergens

Knowledge gaps

Diagnosis of food allergy

When should food allergy be suspected?

Diagnosis of IgE-mediated food allergy

Diagnosis of non-IgE-mediated immunologic adverse reactions to food

Diagnosis of IgE-mediated contact urticaria

Knowledge gaps

Management of nonacute allergic reactions and prevention of food allergy

Management of individuals with food allergy

Management of individuals at risk for food allergy

Prevention of food allergy

Knowledge gaps

Diagnosis and management of food-induced anaphylaxis and other acute allergic reactions to foods

Definition of anaphylaxis

Diagnosis of acute, life-threatening, food-induced allergic reactions

Treatment of acute, life-threatening, food-induced allergic reactions

Management of food-induced anaphylaxis

Knowledge gaps

Sources of funding
Publication of this article was supported by the Food Allergy Initiative.
Disclosure of potential conflict of interest:

•	J. A. Boyce has served on the Advisory Board of GlaxoSmithKline. He has served as a consultant and/or speaker for Altana, GlaxoSmithKline, and Merck. He has received funding/grant support from the National Institutes of Health.
•	A. Assa’ad holds, or is listed as an inventor on, US patent application #10/566903, entitled “Genetic markers of food allergy.” She has served as a consultant for GlaxoSmithKline and as a speaker for the American College of Allergy, Asthma, and Immunology, the North East Allergy Society, the Virginia Allergy Society, the New England Allergy Society, and the American Academy of Pediatrics. Dr Assa’ad has received funding/grant support from GlaxoSmithKline.
•	A. W. Burks holds, or is listed as an inventor on, multiple US patents related to food allergy. He owns stock in Allertein and MastCell, Inc, and is a minority stockholder in Dannon Co Probiotics. He has served as a consultant for ActoGeniX NV, McNeil Nutritionals, Mead Johnson, and Novartis. He has served on the speaker’s bureau for EpiPen/Dey, LP, and has served on the data monitoring committee for Genentech. He has served on an expert panel for Nutricia. Dr Burks has received funding/grant support from the Food Allergy and Anaphylaxis Network, Gerber, Mead Johnson, and the National Institutes of Health.
•	S. M. Jones has served as a speaker and grant reviewer and has served on the medical advisory committee for the Food Allergy and Anaphylaxis Network. She has received funding/grant support from Dyax Corp, the Food Allergy and Anaphylaxis Network, Mead Johnson, the National Peanut Board, and the National Institutes of Health.
•	H. A. Sampson holds, or is listed as an inventor on, multiple US patents related to food allergy. He owns stock in Allertein Therapeutics. He is the immediate past president of the American Academy of Allergy, Asthma, and Immunology. He has served as a consultant for Allertein Therapeutics, the American Academy of Allergy, Asthma, and Immunology, the Food Allergy Initiative, and Schering Plough. He has received funding/grant support for research projects from the Food Allergy Initiative, the National Institutes of Health (Division of Receipt and Referral, National Institute of Allergy and Infectious Diseases, National Center for Complementary and Alternative Medicine), and Phadia AB. He is a co-owner of Herbal Spring, LLC.
•	R. A. Wood has served as a speaker/advisory board member for GlaxoSmithKline, Merck, and Dey. He has received funding/grant support from Genentech and the National Institutes of Health (National Institute of Allergy and Infectious Diseases).
•	S. H. Arshad has received funding/grant support from the National Institutes of Health and the National Institute of Health Research, UK.
•	S. L. Bahna has received funding/grant support from Genentech.
•	L. A. Beck has received funding/grant support from the American Academy of Allergy, Asthma, and Immunology, the National Eczema Association, and the National Institutes of Health.
•	C. Byrd-Bredbenner owns stock in Johnson & Johnson. She has received funding/grant support from the US Department of Agriculture, the Canned Food Alliance, and the New Jersey Department of Health and Senior Services.
•	C. A. Camargo Jr has consulted for Dey and Novartis. He has received funding/grant support from a variety of government agencies and not-for-profit research foundations, as well as Dey and Novartis.
•	L. Eichenfield has received funding/grant support from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson & Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.
•	G. T. Furuta has served as a consultant and/or speaker to Ception Therapeutics and TAP. He has received funding/grant support from the American Gastrointestinal Association and the National Institutes of Health.
•	J. M. Hanifin has served as served as a consultant for ALZA, Anesiva, Inc, Barrier Therapeutics, Inc, Milliken & Company, Nordic Biotech, Novartis Pharmaceuticals Corporation, Shionogi USA, Taisho Pharmaceutical R&D, Inc, Teikoku Pharma USA, Inc, UCB, York Pharma, ZARS, Inc, and ZymoGenetics. He has served as an investigator or received research funding from ALZA, Astellas Pharma US, Inc, Asubio Pharmaceuticals, Inc, Centocor, Inc, Corgentech, Novartis, Nucryst Pharmaceuticals, Seattle Genetics, and Shionogi USA.
•	M. Kraft has served as a consultant and/or speaker for Astra-Zeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sepracor. She has received funding/grant support from Genentech, GlaxoSmithKline, the National Institutes of Health and Novartis.
•	B. D. Levy holds, or is listed as an inventor on, US patent applications #20080064746 entitled “Lipoxins and aspirin-triggered lipoxins and their stable analogs in the treatment of asthma and inflammatory airway diseases” and #20080096961 entitled “Use of docosatrienes, resolvins and their stable analogs in the treatment of airway diseases and asthma.” He owns stock in Resolvyx Pharmaceuticals. He has served as a consultant for Bayer Healthcare and Resolvyx Pharmaceuticals. Dr Levy has received funding/grant support from the National Institutes of Health.
•	P. Lieberman has served as a consultant and/or speaker to Dey Laboratories, Novartis, Schering-Plough, AstraZenica, Merck, TEVA, Pfizer, MEDA, Alcon, Genentech, Intelliject, and the Food Allergy and Anaphylaxis Network. He is past president of the American Academy of Allergy, Asthma, and Immunology.
•	L. C. Schneider has served as a consultant/clinical advisor for the Food Allergy Initiative. She has received funding/grant support from a variety of not-for-profit research foundations, as well as Novartis and the National Institutes of Health.
•	R. A. Simon has served as a speaker for Dey Laboratories, Genentech, GlaxoSmithKline, Merck, Novartis, and the US Food and Drug Administration.
•	F. E. R. Simons holds a patent on “Fast-disintegrating epinephrine tablets for sublingual administration.” She is a past-president of the American Academy of Allergy, Asthma, and Immunology and of the Canadian Society of Allergy and Clinical Immunology. She is a member of the advisory boards of Dey, Intelliject, and ALK-Abello. She has received funding/grant support from AllerGen, the Canadian Allergy, Asthma and Immunology Foundation/Anaphylaxis Canada, and the Canadian Institutes of Health Research.
•	S. J. Teach has served as a speaker for AstraZeneca. He has received funding/grant support from the AstraZeneca Foundation, Aventis, the Child Health Center Board, the CNMC Research Advisory Council, the National Association of Chain Drug Stores Foundation, the National Institutes of Health (National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute), Novartis/Genentech, the Robert Woods Johnson Foundation, the US Centers for Disease Control and Prevention, the US Public Health Service, and the Washington, DC, Department of Health.