Of interest to many of us, I think?
Pamela Morrison IBCLC
Rustington, England
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Medscape
NIAID Releases First Guidelines for Managing Food Allergies
Emma Hitt, PhD
December 6, 2010 — The first food allergy
guidelines were issued today by the National
Institutes of Health's National Institute of
Allergy and Infectious Diseases (NIAID).
According to the new guidelines, avoiding the
ingestion of specific allergens is the main
strategy suggested for managing food allergies,
and no medications are currently recommended.
Developed over 2 years, the guidelines are
intended for use by both family practice
physicians and medical specialists and were
published online today by the Journal of Allergy
and Clinical Immunology. The full text of the
guidelines are now available on the NIAID Web site.
Joshua A. Boyce, MD, from the Division of
Rheumatology, Immunology and Allergy at Brigham
and Women's Hospital in Boston, Massachusetts,
chaired the 19-member panel of experts that
devised the new guidelines. The NIAID also
established a coordinating committee with members
from 34 professional organizations, advocacy groups, and federal agencies.
"These guidelines are an important starting point
toward a goal of a more cogent, evidence-based
approach to the diagnosis and management of food
allergy," Dr. Boyce said in an NIAID news
release. "We believe that they provide healthcare
professionals with a clear-cut definition of what
constitutes a food allergy and a logical
framework for the appropriate use of diagnostic
testing and accurate interpretation of the results."
The guidelines, which include 43 clinical
recommendations, discuss both IgE-mediated
reactions to food and some non-IgE-mediated
reactions. The panel defines food allergy as "an
adverse health effect arising from a specific
immune response that occurs reproducibly on exposure to a given food."
Food Allergies Increasing in US
The natural history of the most common food
allergens in the United States — including egg,
milk, peanut, tree nuts, wheat, crustacean
shellfish, and soy — was reviewed and summarized.
The incidence and prevalence of food allergies
were found to have possibly changed over time,
with many studies suggesting a true increase in
prevalence over the last 10 to 20 years.
According to the literature summary in the new
guidelines, most children with allergies to milk,
egg, soy, and wheat will eventually be able to
tolerate these allergens, while tree nut and
peanut allergies are less likely to resolve with
time. Likewise, food allergies that begin in adulthood are likely to persist.
The guidelines also note that food allergies tend
to coexist with asthma, atopic dermatitis,
eosinophilic esophagitis, and exercise-induced
asthma. Eliminating food allergens can improve
symptoms of some of these comorbid conditions.
Guidelines Recommend Confirmation of Allergies
The guidelines also describe conditions that
should raise clinical suspicion of food
allergies. In addition, they suggest that food
allergies should be confirmed, because studies
indicate that 50% to 90% of presumed food
allergies are, in fact, not allergies.
The new guidelines will help physicians to know
which tests have been scientifically evaluated to
diagnose food allergy. Matthew Fenton, PhD, with
the NIAID, explained at a press conference held
Friday regarding the new guidelines.
"The guidelines have indicated what the strengths
and weaknesses are of the different tests that
can be used for the diagnosis," said Hugh
Sampson, MD, with the Mount Sinai School of
Medicine in New York City. After a patient
history, skin and blood tests, "the oral food
challenge is the only way to get to the answer," he added.
Vaccines in Egg-Allergic Populations
The guidelines also suggest that patients
allergic to eggs should receive the measles,
mumps, and rubella vaccine despite it being
egg-based. Administering the egg-based yellow
fever and rabies vaccines to these patients was
not supported by a summary of the literature, and
insufficient evidence was found to recommend the
egg-based influenza vaccine for these patients.
"These vaccines can be quite safe in egg-allergic
populations," Dr. Fenton said, "probably in part
due to a continued lowering of the amount of
contaminating egg protein in the vaccine, as
manufacturing methods continue to improve over time."
The panel defines patients at risk for developing
food allergies as "those with a biological parent
or sibling with existing, or history of, allergic
rhinitis, asthma, atopic dermatitis, or food
allergy." However, these patients do not need to
limit exposure to foods that may be
cross-reactive with the most common food allergens.
Delaying of Foods Not Warranted
The guidelines do not recommend restricting
maternal diet during pregnancy or lactation to
prevent the development or clinical course of
food allergies, but they do recommend exclusive
breast-feeding of all infants until age 4 to 6
months, unless medical reasons contraindicate breast-feeding.
According to Dr. Sampson, the guidelines concur
with current American Academy of Pediatrics
guidelines. "There is no evidence that delaying
certain foods, even foods that are considered
allergenic, (is) going to have any significant
effect on the development of allergy," he said.
Epinephrine the First Choice for Anaphylaxis
The recommended therapy for anaphylaxis is
described in the guidelines. Dr. Sampson stressed
that "epinephrine is the first choice for the
treatment of anaphylaxis and many of the other
drugs, such as antihistamines, corticosteroids,
and such, are secondary medications."
"The food allergy guidelines provide a rigorous
assessment of the state of the science, and
clearly identify the areas where evidence is
lacking and where research needs to be pursued,"
Daniel Rotrosen, MD, director of the Division of
Allergy, Immunology and Transplantation at NIAID,
said in the news release. "This information will
help shape our research agenda for the near future."
Dr. Boyce serves on the advisory board of
GlaxoSmithKline, has served as a consultant
and/or speaker for Altana, GlaxoSmithKline, and
Merck, and has received funding and grant support
from the National Institutes of Health.
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