1/6/14. Food Allergies: Not Just Peanuts, Eggs, and Milk Pinkus Goldberg MD, FAAAAI, FACAAI, CPI Karen Rance DNP, RN, CPNP, AE- C.

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1 Food Allergies: Not Just Peanuts, Eggs, and Milk Pinkus Goldberg MD, FAAAAI, FACAAI, CPI Karen Rance DNP, RN, CPNP, AE- C Disclaimers Dr. Goldberg speaks on behalf of Baxter, Merck, Mylan, Genetech, and Meda Pharmaceuticals. He conducts clinical research for Glaxo Smith Kline, Merck, Teva, and Genentech. Dr. Rance speaks on behalf of Merck, Genentech, and Meda Pharmaceuticals, as well as Aerocrine. Objectives Identify an evidence- based approach to managing food allergy patients with both common and less common allergens Discuss how to screen for possible sensitivity to food additives and preservatives Describe a management approach for patients with multiple food allergies Overview of Food Allergy An immunological response to primarily a food protein whose reactions can be severe or life- threatening. The allergic reaction results from the production of specific Immunoglobulin E (IgE) antibodies directed against food antigens. Food allergy is the most common cause of anaphylaxis either inside or outside of the Emergency Department. Must be differentiated from food intolerances and other adverse food reactions Burks, A., Tang, M., Sicherer, S., Muraro, A., Eigenmann, P. A., Ebisawa, M.,... & Sampson, H. A. (2012). ICON: food allergy. Journal of Allergy and Clinical Immunology, 129(4), Types of Adverse Food Reactions Nontoxic Toxic Natural History Exposure Genetic Predisposition Food Allergy Food Intolerance Non- IgE IgE Other Metabolic Pharmacologic Idiosyncratic IgE & Non- IgE Sensitization Re- exposure Symptoms Adapted; Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer

2 Food Allergy (FA) Prevalence is Increasing Self- reported prevalence of FA is 8.96%: children = 6.53% and adults = 9.72% Estimated that 2 children in every classroom of 25 children have FA Children with FA are more likely to have asthma or other allergic conditions than those without FA In the last 10 years, food- induced anaphylaxis hospitalizations has increased more than 3- fold. 170 foods have been identified as causing an IgE- mediated response 8 Foods Cause 90% of IgE- Mediated Food Allergy American Academy of Allergy, Asthma, and Immunology. (2013). Updated prevalence of food allergy in the United States. Retrieved from research- summaries/current- JACI- Research/food- allergy- in- us.aspx Boyce, J. A., Assa'ad, A., Burks, A. W., Jones, S. M., Sampson, H. A., Wood, R. A.,... & Schwaninger, J. M. (2010). Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID- sponsored expert panel. The Journal of allergy and clinical immunology, 126(6 Suppl), S1. Burks, A., Tang, M., Sicherer, S., Muraro, A., Eigenmann, P. A., Ebisawa, M.,... & Sampson, H. A. (2012). ICON: food allergy. Journal of Allergy and Clinical Immunology, 129(4), The Natural History of Peanut Allergy Peanut allergy affects 1% of children There is a strong association between higher IgE levels and reaction severity. The annual incidence rate of accidental exposure for children with peanut allergy is 12.5%. Children and adolescents are at higher risk. The Natural History of Egg Allergy Medical records of 581 pts reviewed at pediatric allergy clinic for those outgrowing egg allergy By age 4 4% By age 6 12% By age 10 37% By age 16 68% By age 18 80% Nguyen- Luu, N. U., Ben- Shoshan, M., Alizadehfar, R., Joseph, L., Harada, L., Allen, M.,... & Clarke, A. (2012). Inadvertent exposures in children with peanut allergy. Pediatric Allergy and Immunology, 23(2), Neuman- Sunshine, D. L., Eckman, J. A., Keet, C. A., Matsui, E. C., Peng, R. D., Lenehan, P. J., & Wood, R. A. (2012). The natural history of persistent peanut allergy. Annals of Allergy, Asthma & Immunology, 108(5), Savage, J. H., Matsui, E. C., Skripak, J. M., & Wood, R. A. (2007). The natural history of egg allergy. Journal of Allergy and Clinical Immunology, 120(6), The Natural History of Milk Allergy Research: in cohort of infants (#293) with milk allergy, 50% resolved over 66 months of follow up. Baseline milk- specific IgE level, SPT wheal size, and AD severity were important predictors of the likelihood of resolution. Determining Severity of Reactions What Matters Most Coexistent asthma Amount ingested Raw vs. cooked Co- ingestion of other foods Age Degree of sensitization Empty stomach Exercise Near Fatal Reactions Asthma especially severe on chronic corticosteroids Delayed use of epinephrine with reliance on Benadryl Alcohol consumption Wood, R. A., Sicherer, S. H., Vickery, B. P., Jones, S. M., Liu, A. H., Fleischer, D. M.,... & Sampson, H. A. (2012). The natural history of milk allergy in an observational cohort. Journal of Allergy and Clinical Immunology. Boyce, J. A., Assa'ad, A., Burks, A. W., Jones, S. M., Sampson, H. A., Wood, R. A.,... & Schwaninger, J. M. (2010). Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID- sponsored expert panel. The Journal of allergy and clinical immunology, 126(6 Suppl), S1. 2

3 Evidence- based Approach Evidence Based Approach NIAID Food Allergy Guidelines: Guidelines for the Management and Diagnosis of Food Allergy in the United States topics/foodallergy/clinical/ Pages/default.aspx. DRAFT - Joint Task Force on Practice Parameters: Food Allergy: A Practice Parameter Update Diagnostic Evaluation of Food Allergy Diagnostic Approach to the Evaluation of Food Allergy Detailed History and Physical IgE- mediated Combined Non- Ige- mediated ssige GI Consultations/Endoscopy - - Reconsider Reconsider Elimination Diet Food Challenge Reconsider - - Reconsider Specific Allergen=Elimination Diet Adapted from Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update;Vol. 24 #2; Summer 2008 Prick Skin Testing Sporik et al study in 3 yr olds (large cohort) prick testing & food challenges Peanut > 8mm over control Cow s milk > 8 mm over control Egg > 7 mm over control Predictive accuracy approx. 95% specificity for reactions Studies have demonstrated that the wheal size and specific IgE level can be associated with the severity of reactions on oral challenge. Negative predictive accuracy of a properly performed prick test exceeds 95% Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008 Lieberman, J. A., & Sicherer, S. H. (2011). Diagnosis of food allergy: epicutaneous skin tests, in vitro tests, and oral food challenge. Current allergy and asthma reports, 11(1), Lab Testing The comparability of skin testing and selected immunoassays is debatable. However, prior to a food challenge in a patient with a highly suggestive history and a negative in vitro test Prick skin testing is advised Testing Prick skin testing systemic symptoms are rare Glycerinated Fresh food extracts Prick- prick test Positive predictive accuracy < 40% if 3mm greater than control criteria is used Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer 2008 Atkins, Dan; National Jewish Medical Research Center Medical Scientific Update; Vol. 24 #2; Summer

4 Related Diagnoses Cross Reactivity and Food Allergen Groups When an allergic response is established toward a particular protein, presentation of a homologous form of that protein in another substance may also trigger an allergic response. Allergic reaction to multiple foods may follow initial sensitization caused by 1 food or nonfood allergen such as pollen. Food allergens are derived from just a few protein families. Over 70% identity in primary sequence is needed for cross- reactivity. Sicherer, S. H. (2013). 25 Hidden and Cross- Reacting Food Allergens. Food Allergy: Adverse Reaction to Foods and Food Additives. Cross Reactivity: Clinical Application Studies where a patient who is allergic to one member of a food family is challenged to all others in that food group are lacking. Decisions to avoid foods as a group may also be based upon concerns about cross- contact or misidentification of the allergens. Decisions can be individualized based upon clinical judgment, patient preference, nutritional considerations, and availability of safe foods. Sicherer SH; Clinical implications of cross- reactive food allergens JACI; 2001; Sicherer, S. H. (2013). 25 Hidden and Cross- Reacting Food Allergens. Food Allergy: Adverse Reaction to Foods and Food Additives. Oral Allergy Syndrome Reactions occur because the proteins found in some fruits and vegetables are very similar to those found in pollen. These proteins can confuse the immune system and cause an allergic reaction or make existing symptoms worse. Cross- reactivity happens when the immune system thinks one protein is closely related to another. Most frequent reactions involve itchiness or swelling of the mouth face, lip tongue and throat. Individuals react to different foods based on what type of seasonal allergies they are affected by. If a patient develops a pollen allergy prior to developing OAS, the reactions are less likely to be life threatening. Webber, C. M., & England, R. W. (2010). Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Annals of Allergy, Asthma & Immunology, 104(2), Eosinophilic Esophagitis Studies show complete food elimination as EoE s most effective treatment The drawbacks of an elemental diet have led to use of a 6- food elimination diet and skin prick test/atopy patch test- directed diet. Studies show that SPT may lead to better results. Spergel et al reported that 77% of 319 patients with EoE responded to diet modifications guided by SPT/APT plus empiric milk elimination compared with 53% of those on SPT/APT- based elimination alone. Fresh food SPT has been shown to identify food sensitivities not detected with commercial extracts Liacouras, C. A., Furuta, G. T., Hirano, I., Atkins, D., Attwood, S. E., Bonis, P. A.,... & Aceves, S. S. (2011). Eosinophilic esophagitis: updated consensus recommendations for children and adults. Journal of Allergy and Clinical Immunology, 128(1), Holbreich, M. (2008). A comparison of fresh vs commercial extracts for food testing. Journal of Allergy and Clinical Immunology, 121(2), S251. Spergel, J. M., Brown- Whitehorn, T. F., Cianferoni, A., Shuker, M., Wang, M. L., Verma, R., & Liacouras, C. A. (2012). Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. Journal of Allergy and Clinical Immunology. 4

5 Irritable Bowel Syndrome- Diarrhea Predominant In patients with AR, FA, or h/o atopic disease, the odds of IBS- D are 12.0, 6.96, and 4.2, respectively, compared with those who do not have these symptoms. Study: 100 patients who had undergone endoscopies and biopsies with immunostaining for mast cell tryptase were selected from the pathology department s database. In comparison to patients with intestinal mast cell counts less than 15, patients with mast cells/hpf have twice the probability of having IBS- D when controlling for atopic status. In patients with <19 mast cells/hpf, the presence of atopic disease quadrupled the odds of IBS- D. Patch Testing and IBS- D Patch testing may be useful in identifying the causative foods. Study: skin patch testing to common allergenic foods and food additives on individuals with a history of or symptoms suggestive of IBS- D. Patch test guided avoidance diets were used to determine whether avoidance alleviates IBS- D symptoms. Results: 30 of the 51 study participants showed at least 1 positive patch test result. Fourteen of the participants reported symptomatic improvement, ranging from slight to great, upon avoidance of the foods/food additives to which they reacted. Mittel, R. J., Demeo, M., Jakate, S., Mikolaitis, S., Tilmon, S., & Tobin, M. C. (2013). The Relationship Between Atopic Disease, Mast Cell Counts and Irritable Bowel Syndrome- Diarrhea Predominant (IBS- D). Journal of Allergy and Clinical Immunology, 131(2), AB178- AB178. Stierstorfer, M. B., Sha, C. T., & Sasson, M. (2012). Food patch testing for irritable bowel syndrome. Journal of the American Academy of Dermatology. Alpha- Gal Allergy Recent studies have linked the consumption of meat to an alpha- gal allergy causing a reaction to red meat, which occurs after being bitten by a tick and may lead to anaphylaxis. The link is a sugar, commonly called alpha- gal, found in the meat of all non- primate mammals, including cows, pigs, sheep and goats. Drs. Platts- Mills and Cummins at the University of Virginia found that a tick bite (specifically the lone star tick, which is indigenous in the southeastern United States) is a cause, possibly the sole cause, of IgE production related to alpha- gal. The tick bite introduces alpha- gal into the skin of an individual, causing the creation of specific IgE in some people. If not exposed again through another tick bite, the allergy usually resolves within eight months to three years. Allergic Reactions to Food Additives Food additives basic functions: make food safer by preserving it from bacteria and preventing oxidation Food additives are potential hidden allergens as everyone is exposed to them every day Among sensitive subjects, potential of allergic reaction to food additives is reported as % Some food additives may cause an allergic reaction by inhalation or by topical administration, but not just by ingestion Platts- Mills, T. A., & Commins, S. P. (2013). Emerging antigens involved in allergic responses. Current opinion in immunology, 25(6), Gultekin, F., & Doguc, D. K. (2012). Allergic and Immunologic Reactions to Food Additives. Clinical reviews in allergy & immunology, Food Additive Groups Known to Cause Reactions Antioxidants (such as BHA and BHT) Colors (food dyes) Emulsifies and stabilizers (such as gums and lecithin) Solvent Glazing agents (such as stearic acid, beeswax, lanolin, esters) Preservatives (such as benzoates, nitrates, and sulfites) Flavoring and sweetening agents Thickeners Testing for Allergy to Food Additives Patients with adverse reaction to food additives should be evaluated for sensitivity to annatto (yellow) and carmine (red) as they have been linked to anaphylaxis. There is also evidence that erythritol, guar gum, psyllium, carrageenan, lupine, pectin, gelatin, mycoprotein, and certain spices have caused anaphylaxis. Natural food additives and spices should be included in the work- up of patients with a history of unexplained anaphylaxis. Degaetani, M. A., & Crowe, S. E. (2010). A 41- Year- Old Woman With Abdominal Complaints: Is It Food Allergy or Food Intolerance? How to Tell the Difference. Clinical Gastroenterology and Hepatology, 8(9), Nish, W., Whisman, B., Goetz, D., & Ramirez, D. (1991). Anaphylaxis to annatto dye: a case report. Annals of Allergy, Asthma, and Immunology, 66(2): Beaudouin, E., Kanny, G., Lambert, H., Fremont, S., & Moneret- Vautrin, D.(1995). Food anaphylaxis following ingestion of carmine. Annals of Allergy, Asthma & Immunology, 74(5):

6 Case Study: C. Gum 39 year old female History of random and unanticipated tongue and throat swelling for 4 weeks, 3 episodes. Initial episode - ate cream pie (store bought) and developed swelling within 3 minutes. No hives or rash History of IBS- C Case Study: continued Working diagnosis: angioedema suspect something ingested Lab work ordered: ANA, liver enzymes, BUN, creatine, C4, ESR, total IgE level, UA, vitamin D level, thyroid studies, ssige levels for foods and food additives All lab work negative, except for Carrageenan Gum (+) Implemented avoidance diet of C. Gum At 3 month f/u: no incidences of angioedema on C. Gum avoidance. Patient also reported decreased IBS- C symptoms on avoidance diet. Patient declined re- challenge. Dust Mites and Food Allergy House dust mites and storage mites are commonly found in grain, fishmeal, and dried fruit. Dust mite sensitive patients may react to a food that has been in extended storage and exposed to dust mites. Food Induced Allergic Rhinitis The prevalence of food- induced allergic rhinitis appears to be less than 1 percent. Food reactions often lead to rhinitis symptoms without an immunologic nature. Although the role of food and fruits in developing allergic rhinitis is not clearly identified, in a very small percentage of patients, rhinitis is among the clinical manifestations of food allergy. Cui, Y. (2013). Immunoglobulin E- Binding Epitopes of Mite Allergens: From Characterization to Immunotherapy. Clinical reviews in allergy & immunology, Bemanian, M. H., Arshi, S., & Nabavi, M. (2013). Food- induced Allergic Rhinitis. Journal of Pediatrics Review, 1(1), Celiac Disease Celiac disease (CD) is a chronic small intestine immune- mediated condition triggered by exposure to gluten in genetically sensitive individuals (DQ2+ or DQ8+). Gluten is a protein component found in wheat, barley, and rye (but not in oats). The gluten- free diet is currently the only available treatment for CD, although ongoing pharmacological and vaccine trials promise future alternatives. FPIES Food protein- induced enterocolitis syndrome (FPIES) is a non IgE- mediated gastrointestinal food hypersensitivity that manifests as profuse, repetitive vomiting, often with diarrhea, leading to acute dehydration and lethargy or weight loss and failure to thrive if chronic. FPIES is elicited most commonly by milk and soy proteins; however, rice, oat, and other solid foods may also elicit FPIES. Certain FPIES features overlap with food protein- induced enteropathy and proctocolitis, whereas others overlap with anaphylaxis. Usually ST are negative for milk and soy. Ludvigsson, J. F., Biagi, F., & Corazza, G. R. (2014). Epidemiology of Celiac Disease. In Celiac Disease (pp ). Springer New York. Järvinen, K. M., & Nowak- Węgrzyn, A. (2013). Food Protein- Induced Enterocolitis Syndrome (FPIES): Current Management Strategies and Review of the Literature. The Journal of Allergy and Clinical Immunology: In Practice. 6

7 Experimental Approach: Dust Mite Allergy and Shrimp Allergy The presence of allergy to shrimp is currently a hypothetical contraindication to specific immunotherapy for house dust mites. CASE STUDY: A 15 year- old male presented with mild persistent asthma and rhinitis due to mites, and concomitant allergy to shrimps and seafood, with anaphylactic symptoms: urticaria, glottis oedema, asthma, enteritis. CASE STUDY Results The patient underwent SLIT extract for mites without any adverse events. The maintenance dose, regularly achieved, was 5 drops a day for 12 months, that is twice the recommended dose. This was done to achieve a high enough cumulative dose of tropomyosin, that was 146 μg. After 12 months the symptom/medication score decreased by approximately 40% and drug intake for asthma and rhinitis also decreased by 40%. At 12 months an oral challenge with a single shrimp was done, and it caused only an oral allergic syndrome, without systemic symptoms. In addition, the patient accidentally ate shrimps in small quantities at home, without any symptoms. After 12 months of SLIT the average diameter of skin prick test to shrimps was 5 mm; to dermatophagoides pteronyssinus 10 mm; and to dermatophagoides farinae 6 mm. Specific IgE to tropomyosin slightly increased to 53 ku/l, whereas no relevant change was seen in the remaining parameters. Cortellini, G., Spadolini, I., & Santucci, A. (2011). Improvement of shrimp allergy after sublingual immunotherapy for house dust mites: a case report. European annals of allergy and clinical immunology, 43(5), Cortellini, G., Spadolini, I., & Santucci, A. (2011). Improvement of shrimp allergy after sublingual immunotherapy for house dust mites: a case report. European annals of allergy and clinical immunology, 43(5), Role of Diet in Nickel Allergy Skin Conditions Associated with Food Allergy Nickel is a ubiquitous trace element and the commonest cause of metal allergy among people. Nickel allergy is a chronic, recurring problem; females are affected more commonly than males. Nickel allergy may develop at any age. Once developed, it tends to persist life- long. Nickel in the diet of a nickel- sensitive person can provoke dermatitis. Careful selection of foods with relatively low nickel concentrations can bring a reduction in the total dietary intake of nickel per day. Sharma, A. D. (2013). Low nickel diet in dermatology. Indian journal of dermatology, 58(3), 240 Low Nickel Diet Nickel is present in most of the dietary items and food is considered to be a major source of nickel. Nickel when administered orally ( mg) as a single dose provoked hand eczema. Evidence cites improvement of dermatitis on a low nickel diet. Common sources of nickel foods: cereals, fish, canned vegetables, nuts, instant tea and coffee, dried peas. Foods that Contain Nickel High content (> 0.5mg/kg): almond, asparagus, beans, buckwheat, chickpeas, cocoa powder, dark chocolate, fresh pears, hazelnut, herring, linseed, mussels, oat bran, oatmeal, onions, peanut, pistachio nuts, poppy seed, soy beans, soy flour, walnuts, wheat bran, yellow peas. Medium content ( mg/kg): barley, black current, corn flour, eggs, garlic, horseradish, kale, milk chocolate, oysters, parsley, parsnip, raspberries, rice, rye, various mushrooms, yeast. Sharma, A. D. (2013). Low nickel diet in dermatology. Indian journal of dermatology, 58(3), 240. Adams Allergy: Parveneh Abadee, M.D. / Denis J. Yoshii, D.O., 1700 Adams Ave #100, Costa Mesa, CA

8 Balsam of Peru Diet Balsam of Peru, composed of a variety of components, is a fragrance found in foods such as alcohol, citrus fruits, chocolate, pickle vegetables, spices, and tomatoes that has been associated with systemic contact dermatitis. The diagnosis can be made by history and atopy patch testing but also may require dietary elimination or food challenge of the suspicious food or food components. Balsam of Peru is a well- known contact allergen that is one of the most prevalent in the United States. For some patients allergic to BOP, external avoidance of fragrance is not enough to eliminate their dermatitis. Food- Dependent Exercise Induced Anaphylaxis FDEIA is a distinct condition in which anaphylaxis develops only if physical activity occurs within a few hours after eating a specific food. This disorder has been reported with a wide variety of foods. The foods most commonly implicated in food- dependent exercise- induced anaphylaxis include wheat, shellfish, tomatoes, celery, peanuts, and corn. Scheman, A., Rakowski, E. M., Chou, V., Chhatriwala, A., Ross, J., & Jacob, S. E. (2012). Balsam of peru: past and future. Dermatitis: contact, atopic, occupational, drug: official journal of the American Contact Dermatitis Society, North American Contact Dermatitis Group, 24(4), Image: http// dermatologist.com Romano A, Di Fonso M, Giuffreda F, et al. (2001). Food- dependent exercise- induced anaphylaxis: clinical and laboratory findings in 54 subjects. Intl Archives All Imm. 125(3): Allergenicity Management of Food Allergies Fruits and vegetables cause allergic reaction primarily if eaten raw, but may still cause reactions after being thoroughly cooked or having undergone digestion in the stomach and intestines. Sicherer, S. H., & Sampson, H. A. (2010). Food allergy. Journal of Allergy and Clinical Immunology, 125(2), S116- S125. Food Processing and Allergenicity The alteration of allergenicity of a protein during the manufacturing process may determine how provoking the food is The heating process of baking destroys the protein structure to which the child is sensitive For example, some egg sensitive children may be able to tolerate eggs in baked products, but not when eaten alone Allergenicity of Oils Oils are commonly derived from soy, corn, peanut, and sesame They may range in their allergenicity depending on how much of the food protein is removed in process Consuming highly refined oils developed from major allergenic food sources does NOT appear to be associated with allergic response According to the FARE, Studies show that most allergic individuals can safely eat peanut oil (not cold pressed, expelled, or extruded peanut oil - sometimes represented as gourmet oils). Sicherer, S. H., & Sampson, H. A. (2010). Food allergy. Journal of Allergy and Clinical Immunology, 125(2), S116- S125. Food Allergy Research Education. Available at 8

9 Cold Pressed vs. Cooked Oils? Cold pressed oils are obtained trough pressing and grinding fruit or seeds with the use of heavy granite millstones or modern stainless steel presses The temperature must not rise above 120 F (49 C) for any oil to be considered cold pressed. Cold pressed oils retain all of their flavor, aroma, and nutritional value - olive, peanut and sunflower are among the oils that are obtained through cold pressing Cold pressed oils are considered more risky for patients to consume due to their retention of more allergenic proteins. Cross Contact Through Saliva Allergic reactions are possible via saliva exchange, including risks associate with sharing straws, cups and utensils. Discuss appropriateness of peanut- free table in school setting. Allergic Kiss of Death is NOT a myth. The safest strategy is that the family of the food allergic child also avoid the allergenic food. Food Allergy Research Education. Available at Maloney, J. M., Chapman, M. D., & Sicherer, S. H. (2006). Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. Journal of allergy and clinical immunology, 118(3), Food Product Label Manufacturers must detail allergen information for top 8 food allergens (milk, eggs, fish/ crustaceous fish, peanuts, tree nuts, wheat, and soy). Manufacturers must list the specific nut (e.g., almond, walnut, cashew) or seafood (e.g., tuna, salmon, shrimp, lobster) that is used in the product. Products with precautionary labeling, such as this product may contain trace amounts of allergen should be avoided. Food and Drug Administration (FDA). (2013). Food allergen labeling and consumer protection act of FDA website. No. Are Patients Reading Food Labels? Hefle et al. (2007) demonstrated increasing numbers of FA consumers are NOT reading labels precautionary labeling and choosing to ingest products due to: Their stated recognition of increase warnings and therefore not needing to rely on labels FA consumers noting no reaction after ingestions FA consumers presuming that advisory labeling is used for legal reasons only Hefle, et al.(2007). Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. Journal of Allergy Clinical Immunology, 120, Are Precautionary Labels Accurate? Current labeling laws relate only to intentionally added ingredients. Consumers must make risk assessments based on precautionary labeling. When in doubt, don t eat it! Follow Up Allergies to milk, egg, wheat, soy generally resolve more quickly in childhood than peanut, tree nuts, fish and shellfish. Consider the natural course of allergies to specific foods when deciding upon frequency of food allergy follow- up evaluations Hefle, et al.(2007). Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J All Clin Imm, 120,

10 The Future Component- resolved diagnostic testing to food allergen may be considered as in the case of peanut sensitivity, but it is not routinely recommended even with peanut sensitivity because the clinical utility of component testing has not been fully elucidated. Although immunotherapeutic approaches, e.g. such as oral immunotherapy, in clinical trials show promise, they are not ready for implementation in clinical practice at the present time due to inadequate evidence for therapeutic benefit over risks of therapy. 10