Adverse reactions to foods

Transcription

1 Food allergy

2 Adverse reactions to foods Immune mediated Non-immune mediated Toxic reactions IgE-mediated Food allergy Food intolerance Pathophysiology explained Uncleare Toxins Bacterial toxins Aflatoxins Scombroid poisoning Non- IgEmediated Mixed IgE- and non-ige-mediated Coeliac Disease Pharmacological caffeine tyramine Enzyme deficiencies lactose/ fructose malabsorption Non-specific IBS Functional disoredres of GI tract

3 Food allergy - prevalence 1-2% of population Anaphylaxis to food ( 0-19 years) 22 per person years (food allergy anaphylactic reaction /year in USA)

4 Adverse reactions to food Immune mediated (Food allergy, celiac disease) Non-immune mediated IgE-mediated Non-IgE mediated

5 Food allergens Children Milk Eggs Wheat Soy Tree nuts Peanuts Adults Tree nuts Peanuts Fish Shelfish

6 Most frequent symptoms of mild to moderate CMPA Therapeutic area Symptoms Gastrointestinal Dermatological Respiratory General Frequent regurgitation Vomiting Diarrhea Constipationa Blood in stool without failure to thrive Atopic dermatitis Swelling of lips or eye lids Urticaria unrelated to acute infections, drug intake, or other causes Runny nose Recurrent otitis media Chronic cough Broncho-constriction unrelated to infection Persistent distress Colic ( 3 h/day wailing/irritable) over a period of >3 weeks

7 Remember! Different clinical patterns of food allergy may combine in the same patient.

8 Phenotypes of food allergy Transient Persistent (IgE-dependent) Pollen food syndome (Oral allergy syndrome)

9 Allergic march It is hard to predict how one child with allergy will experience this progression compared to another. GI tract food allergy Atopic dermatitis Eosinophilic esophagitis Rhinitis Asthma Poród 0,5 1 3? 18 wiek Food allergens Airborn allergens

10 Pruritis Urticaria Angioedema Vomiting Diarrhea ANAPHYLAXIS Allergic proctocolitis FPIES (food protein induced enterocolitis syndrome) Food proteine induced eneropathy Minutes Acute Hours Delayed Eosinophilic IG tract disorders AD

11 IgE-mediated food allergy Acute Reproducible Typical symptoms Positive tests

12 Non-IgE-mediated food allergy

13 Case history Ingested food and their ingredients Description of symptoms Timing of onset of symptoms Quantity of food to produce symptoms Frequency of reactions and reproducibility Most recent occurrence Accompanying factors (e.g., exercise, intake of other foods, drugs, coffee, alcohol, infections, stress, etc.) Diary reporting symptoms and food intake

14 In vitro assays Determination of total lge Determination of specific lge antibodies to food allergen extracts Component-resolved allergy diagnosis with single food allergens or in multiplex assays lge immunoblots or lge ELISA with allergy-causing food extract Basophil activation test Direct basophil activation Histamine release Leukotriene release CD63, CD203c, upregulation Passive basophil activation tests T cell proliferation assays Cytokine secretion assays

15 Skin tests Elimination/ reinroduction diets Skin prick test (SPT) "Prick-prick" test Intradermal skin test Atopy patch test Baseline registration of symptoms Diet period Provocation tests Open oral challenge with native foods/- additives Single or double-blind oral challenge with selected foods lntragastral provocation under endoscopic control (IPEC) Colonoscopic allergen provocation test (COLAP)

16 Skin prick tests (SPT) (native, commerciale) Diagnosis

17 Atopy patch tests Diagnosis

18 Case history In vitro assays Skin tests Elimination/ reinroduction diets Identification of the disease-causing allergens Provocation tests Management of lge-associated food allergy Allergen-specific: avoidance diet Allergen-specific: immunotherapy (SIT) Unspecific: Symptomatic medication (antihistamines, antileukotrienes, steroids, epinephrine) Anti-lgE treatment

19 Final diagnosis History Elimination diet

20 Treatment Strict dietary avoidance of the offending food Nutritional planning: dietitian Use of self-injectable epinephrine in case of accidental exposure with allergic reaction Monitoring (nutritional status, antropometry) Oral food challenge: tolerance?

21 Treatment Many individuals will eventually outgrow their food allergies, a substantial number will not. Protection from food-triggered reactions Immune-modulating therapies (development of tolerance) oral immunotherapy sublingual immunotherapy epicutaneous immunotherapy.

22 Cow milk protein allergy (CMPA)? CMPA based on symptoms? +/- specyfic IgE/ SPT Breastfed baby Continue BF, mother on CM-free diet For 2-4 weeks Symptoms improve or disappear Formula fed baby Anaphlaxis (spec IgE positive or pos SPT) 2-4 weeks AAF Symptoms improve or disappear Formula fed baby No anapyhylaxis EHF 2-4 weeks (soy or erhf if ehf not accepted) Symptoms improve or disappear No Yes No Yes No Yes Reconsider compilance Consult dietician & medical specialist Not CMPA? Not CMPA Not CMPA Consider Cow s milk challenge May not be undertaken if clinical diagnosis is obvious or symptoms are life threatening SPT: skin prick test BF: breastfeeding AAF: amini acid based formula E(R)HF: extensive (rice) hydrolysate formula Long-term management Elimination of cow milk sources Consider: Breast milk as the first option Extensively hydrolyzed formula (CM/Rice)/ Soy formula / AAF For at least 6 months or until 9 to 12 months of age Monitor for tolerance

23 Food Allergy Action Plan Emergency Care Plan Name: DOB: 10/2/2014 Allergy to: *** Weight: kg Asthma: yes no Childis Extremely reactive to the following foods: THEREFORE: [ ] If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten. [ ] If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted Any SEVERE SYMPTOMS after suspected or known ingestions. OR one or more of the following: Lung: Short of breath, wheeze, repetitive cough Heart:Pale, blue, faint, weak pulse, dizzy, confused Throat:Tight, hoarse, trouble breathing/swallowing Mouth: Obstructive swelling (tongue and/or lips) Skin: Many hives over body OR combination of symptoms from different body areas: Skin: Hives, itchy rashes, swelling (e.g., eyes, lips) Gut: Vomiting, diarrhea, crampy pain MILD SYMPTOMS ONLY: Mouth:Itchy mouth Skin: A few hives around mouth/face, mild itch Gut: Mild nausea/ discomfort 1. INJECT EPINEPHRINE IMMEDIATELY 2. Call Begin monitoring (see box below) 4. Give additional medications:* - Antihistamine - Inhaler (bronchodilator) if asthma *Antihistamines & inhalers/bronchodilators are not to be depended upon to treat a severe reaction (anaphylaxis). USE EPINEPHRINE. 1. GIVE ANTIHISTAMINE 2. Stay with student: alert healthcare professionals and parent. 3. If symptoms progress (see above), USE EPINEPHRINE 4. Begin monitoring (see box below)

24 Medications/Doses Epinephrine (brand and dose): Antihistamine (brand and dose): Additional Contact Information: Parent's Name (other contacts) and Contact Numbers DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN IF PARENTS CAN NOT BE REACHED!! Monitoring: Stay with child; alert healthcare professionals and parents. Tell rescue squad epinephrine was given; request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See back/ attached for auto-injection technique. Nearest Hospital: Phone: Address: Allergist Name: Phone: Pediatrician Name: Phone: Date Parent's Signature Date Name: Phone: Phone #2: Name: Phone: Phone #2: Additional Contact Information: Parent's Name (other contacts) and Contact Numbers DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN IF PARENTS CAN NOT BE REACHED!!

25 FPIES Food protein induced enterocolitis syndrome Chronic Intermittent vomiting Chronic diarrhea (blood and mucous) Letarghy Pallor Abdominal distention Dehydration Weight loss Failure to thrive Acute Repetitive vomiting (1-3 h after digestion) Diarrhea (5 h after digestion) Wzdęcie brzucha Letarghy Pallor Dehydration Hypotension Hypothermia

26 FPIES - allergens Infants Young children Adolescents Adults milk soy rice owies, pszenica, jęczmień, żyto eggs green peas chicken, turkey, fish Fish Shelfish

27 FPIES laboratory tests Chronic Anemia Hipoalbuminemia Neutrophilia Eozynofilia Metabolic acidosis Methemoglobulinemia Acute Neutrophilia Thrombocytosis Metabolic acidosis Methemoglobulinemia Blood in stool IgE spec (-) (+) APT (-) (+)

28 Treatment of acute FPIES (wg Nowak-Węgrzyn) Fluids Methylprednizolone Ondansetron 20 ml/kg. 0,9% NaCl IV in 10 min 1 mg/kg. (max 60 mg) dożylnie 0,2 mg/kg IV

29 Allergic proctocolitis A common cause of rectal bleeding in an otherwise healthy young infant. In exclusively breast fed or formula supplemented or fed infants. It is characterized by inflammation of the distal colon in response to one or more food proteins, through a mechanism that does not involve immunoglobulin E (IgE). Cow's milk and soy protein are common triggers. A diagnosis of allergic colitis (1)characterized clinically by rectal bleeding; (2) exclusion of infectious causes of colitis (3) disappearance of symptoms after elimination of cow s milk and dairy products from the child s and/or the mother s diet. In most cases resolves by late infancy.

30 Patient with blood streaked stool Medical history Patient's age General condition Physical examination 3 8 week old infant Good general condition Mild bleeding Exclusively breast feeding Cows' milk protein in mother's diet Red blood cell count Peripheral eosinophilia Tentative diagnosis: Begin eosinophilic proctocolitis Hypoalbuminaemia Restriction of cows' milk protein from mother's diet Resolution of bleeding within hours Re-evaluation Proto colonoscopy Biopsy Progressive bleeding The elemental amino acid-based formula