• Finnish Medical Society Duodecim. Paediatric food hypersensitivity and allergy. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Apr 10 [Various]. [13 references]

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Food hypersensitivity and allergy. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2006 Dec 13 [Various].

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

• Food hypersensitivity includes both food allergy and food intolerance.
• In food allergy, the symptoms are related to an immunological mechanism. A skin-prick test or tests for specific immunoglobulin E (IgE) antibodies in the serum may be used in the determination of an immunological mechanism.
• Most infants suffering from food allergy to nutritionally important foods (milk, cereals) recover at pre-school age.
• School-aged children may develop allergy to vegetables or fruit.

Epidemiology

• Up to half of the parents of children younger than 2 years of age associate some of the child's symptoms with food, however, most suspicions of allergy dissolve with time (Eggesbo et al., 1999).
• In a survey of school children, 24% reported to be or to have been allergic to food at some point (Csonka et al., 2000).

Prevention

• To prevent allergies, the risk groups should be identified reliably, and an efficient preventative measure should be available (Csonka et al., 2000).
• Maternal antigen avoidance during lactation has no effect on the incidence of atopic eczema in the child according to one small study (Kramer & Kakuma, 2006) [D].
• Maternal avoidance of food allergens during pregnancy (third trimester) does not prevent atopic manifestations in the infant (Kramer & Kakuma, 2006) [C].
• All studies concerning prevention have been carried out in children at high risk of atopy, and the evidence has been reviewed to be of poor quality (Brand, Vlieg-Boerstra, & Dubois, 2007).
• Exclusive breast feeding for at least 4 to 6 months is recommended, but the allergy-preventing effect of this is modest at best (Kramer & Kakuma, 2002).
• Partially hydrolysed formulas are effective when breast-feeding is not available for high-risk infants (at least one first-degree relative with correctly diagnosed allergy) (Baumgartner et al., 1998; Osborn & Sinn, 2003) [A]. These products may not be marketed in all countries.

Causes of Food Allergy

• In principle any food can cause allergy. There is no allergy-safe diet.
• If a baby does not eat a particular food substance, he/she cannot become sensitised to it. He/she also cannot develop tolerance to it.
• See the Finnish Medical Society Duodecim guideline "How to Investigate Symptoms Associated with Foods?"

Cow's Milk and Cereal Allergies

• Nutritionally most significant (Räsänen & Ylönen, 1992)
• Mainly seen in young children
• Rarely after pre-school age
• Symptoms caused by these foods usually appear in infancy soon after the food has been introduced to the child's diet.
• See the Finnish Medical Society Duodecim guideline "Cow's Milk Allergy."

Allergens Related to Birch Pollen Allergy

• Allergens associated with birch pollen allergy include the following:
  • Root vegetables: potato, carrot, celery, parsnip
  • Fruit and other vegetables: apple, pear, peach, kiwi fruit, plum, mango, tomato, sweet pepper
  • Spices: mustard, caraway, turmeric, ginger, cinnamon
  • Others: walnut, almond
• In most cases preparation of vegetables (cutting, freezing, and especially cooking) removes the allergenicity, the majority of persons allergic to birch pollen can eat cooked vegetables.
• After pre-school age, the avoidance of allergens should be based on symptoms, not test results. Due to cross-reactions, the number of false-positive results is high in skin-prick and radioallergosorbent test (RAST) testing, and they are therefore not recommended.

Other Allergens

• Peanuts, soya, fish, shellfish, eggs, wheat, barley, oats, rye, buckwheat, banana, avocado
• Linseeds, sesame seeds and poppy seeds
• Mushrooms, especially shiitake
• Causes of intolerance (no allergy mechanism)
  • Strawberry, citrus fruit, chocolate, tomato
• Alcoholic drinks
  • Cereal allergens, aniseed, colouring agents, metabisulphite, benzoic acid

Anaphylactic Reaction

• May, in theory, occur with any food
• In infants with milk and egg allergy
• Possible allergens both in children and adults: fish, shellfish, peanuts, soya, celery, kiwi fruit, linseeds and sesame seeds

Symptoms of Food Allergy

• Typically several symptoms are manifested: stomach pain, diarrhoea, cutaneous eruptions, etc.
• In 50% to 80% of infants admitted to hospital with atopic eczema (i.e., with severe eczema, a food allergy is found to aggravate the symptoms) (Isolauri & Turjanmaa, 1996).
• Atopic eczema can also be exacerbated by air-borne allergens: birch pollen in the spring, grass pollen suspended in water and contact with pets (eczema in areas exposed to air is suggestive).
• Eczema can also occur in contact areas (touching a dog, peeling potatoes).
• Of gastrointestinal symptoms, the most obvious one is contact allergy around the mouth and lips which appears almost immediately after ingestion and is easy to connect with the food (tomatoes, citrus fruit and apples in those allergic to birch pollen).
• Other symptoms that appear soon after ingestion of the food (loose stools, vomiting) are also rather easy to connect with the allergen, especially if the association occurs repeatedly.
• Delayed gastrointestinal reactions, or worsening of the atopic eczema, are very difficult to associate with a particular food.
• The frequency of bowel motions varies greatly between individuals. For example, in infancy defecation 10 times a day or once a week may be normal (provided that the child is well and developing normally).
• All changes in the diet can cause temporary changes in bowel function, as can courses of antibiotics.

Other Symptoms

• Food hypersensitivity may also be linked to exacerbation of asthma.
• There is no evidence supporting an association between food (hypersensitivity) and migraine, arthritis, cystitis or nephritis.

Diagnosis of Food Hypersensitivity

• See also the Finnish Medical Society Duodecim guidelines "Cow's Milk Allergy" and "How to Investigate Symptoms Associated with Foods" ("Food allergy in children," 2005; Vandenplas et al., 2007).
• As a basic rule, skin or blood testing of older children for food hypersensitivity should be avoided unless there is a strong suspicion.
• The diagnosis should be based on elimination and reintroduction trials (see clinical algorithm, "Diagnostic work-up of food allergy" in the original guideline document). For the nutritionally important foods (milk and wheat in young children) a more formal elimination-challenge test should be carried out (e.g., in the fashion described below).
  • The suspected food(s) are eliminated from the diet totally (for 1 to 2 weeks).
  • The onset/disappearance of symptoms is recorded in a symptom diary.
  • Reduction or disappearance of symptoms supports food allergy, but is not diagnostic. The food needs to be reintroduced (challenge).
  • A small amount of the food is reintroduced to the diet and, as long as the child remains asymptomatic, the amount is increased gradually to the normal (age-adjusted) amount consumed daily.
  • Symptoms usually reappear within a week (symptom diary) after consuming large enough amounts.
• History reveals immediate reactions. Foods that are nutritionally less important need not be tested but can be eliminated from the diet and reintroduced at a later stage.
• Suspicion of anaphylactic reactions caused by food: careful analysis of the causative factor. NEVER instruct the patient to reintroduce the suspected food at home.
• Positive skin prick tests or the presence of specific IgE antibodies are not enough for a diagnosis. IgA and IgG antibodies are detected in everyone and are not useful in diagnostics.
• Patch or epicutaneous test is a method used in scientific research with selected patients in specialist settings. It is not a routine test method.

Follow-Up

• Specific items of food that are not nutritionally important may be eliminated when the association between the symptoms and food is clear. Elimination reintroduction can be carried out at home whilst keeping a symptom diary.
• There are no adequate trials on how these children should be followed up. Clinical experience therefore dictates the routines.
• Indications for referral to specialist care
  • An infant with widespread eczema or worsening symptoms
  • An infant with difficult or perplexing symptoms, and the parents are convinced of food allergy
  • Failure to thrive
  • Diet limited by the parents to dangerously few foods
  • An older child needs to be referred if the diet threatens to become too limited
• In primary care
  • The growth of a child on an elimination diet is monitored by growth charts.
  • Vaccinations are given according to the normal programme. Allergy to eggs does not prevent vaccination unless the child has had an anaphylactic reaction to eggs (Aickin, Hill, & Kemp, 1994).
  • The family is encouraged to expand and rationalise the diet towards a normal diet.
  • The child's diet should be re-evaluated at 5 years of age at the latest: is the avoidance of certain foods based on an elimination-challenge test? Should a specialist re-evaluate the situation?
  • All elimination diets at school-age should be based on an established diagnosis.

Related Resources

Refer to the original guideline document for related evidence, including Cochrane reviews and other evidence summaries.

Definitions:

Classification of the Quality of Evidence

GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

The clinical algorithm "Diagnostic work-up of food allergy" is provided in the original guideline document.

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

• Finnish Medical Society Duodecim. Paediatric food hypersensitivity and allergy. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Apr 10 [Various]. [13 references]

Not applicable: The guideline was not adapted from another source.

2004 Sep 15 (revised 2008 Apr 10)

Finnish Medical Society Duodecim - Professional Association

Finnish Medical Society Duodecim

Editorial Team of EBM Guidelines

Primary Author: Minna Kaila

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Food hypersensitivity and allergy. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2006 Dec 13 [Various].

None available

None available

This NGC summary was completed by ECRI on August 29, 2005. This summary was updated by ECRI on February 27, 2007. This summary was updated by ECRI Institute on September 27, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.