Food Allergy: Epidemiology, Diagnosis and Management in the Medical Home Presentation Slides

53 Pages·2015·2.43 MB·English

1/27/2015
Welcome to the Educational Webinar on 
Food Allergy: Epidemiology, Diagnosis and 
Management in the Medical Home
Goal of Program:  To improve outcomes for all children with asthma, allergy and 
anaphylaxis via the provision of comprehensive team‐based, family‐centered care 
and effective co‐management between primary and subspecialty care settings. 
PRESENTERS: Ruchi Gupta, MD, MPH, FAAP, FAAAAI
John Lee, MD, FAAAAI
Michael Pistiner, MD, MMSc, FAAP, FAAAAI, FACAAI
• Please select the telephone audio option if your audio option is the telephone
• The Presentation will begin at 7pm ct.
Presenter: R. Gupta
NIAID Guidelines for the Diagnosis and 
Management of Food
• NIAID collaboration to offer concise guidelines 
for healthcare professionals
• Recommendations on 
– Diagnosis
– Testing
– Management non‐life‐threatening allergic 
reactions 
– Diagnosis and management of food 
induced anaphylaxis
• Offered in full guidelines, summary for 
healthcare professionals and summary for 
parents and caregivers
http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx
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Presenter: R. Gupta
Learning Objectives
• Definition & Epidemiology
• Physical Examination & Clinical History
• Diagnostic Testing
• Food Allergy Management
– Epinephrine 
– Education
• Referral to an Allergist
Presenter: R. Gupta
Definitions 
• Food allergy: An adverse health effect arising
from a specific immune response that occurs 
reproducibly on exposure to a given food.
• Anaphylaxis: A serious allergic reaction that is 
rapid in onset and may cause death. 
___________________________________________________________________________________________________________________________________________
Boyce et al. “Guidelines for the Diagnosis and Management of Food Allergy in the United States: 
Report of the NIAID‐Sponsored Expert Panel.” J Allergy ClinImmunol.2010; 126: S8‐S9.
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Presenter: R. Gupta
Prevalence
3-8% of U.S. children have a food allergy
___________________________________________________________________________________________________________________________________________
Boyce et al. “Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID‐Sponsored Expert Panel.” J Allergy ClinImmunol.2010; 
126: S11.
Gupta RS, SpringstonEE, WarrierMR, Smith B, Kumar R, PongracicJ, HollJL. The prevalence, severity, and distribution of childhood food allergy in the United States. 
Pediatrics2011 Jul; 128(1):e9‐e17.
Rona, R.J., Keil, T., Summers, C., Gislason, D., Zuidmeer, L., Sodergren, E. et al. The prevalence of food allergy: a meta‐analysis. J Allergy ClinImmunol. 2007 Sep; 120: 638–646
Branum, Amy M., and Susan Lukacs. Food allergy among US children: trends in prevalence and hospitalizations. US Department of Health and Human Services, Centersfor 
Disease Control and Prevention, National Center for Health Statistics, 2008.
Sicherer, Scott H. "Epidemiology of food allergy." Journal of Allergy and Clinical Immunology 127.3 (2011): 594‐602.
Jackson, Kristen D., L. D. Howie, and Lara J. Akinbami. "Trends in allergic conditions among children: United States, 1997–2011." NCHS data brief 121 (2013): 1‐8.
Prevalence Presenter: R. Gupta
Most common childhood (<18 yo) food allergens:
30%
Peanut
25.2%
25%
Milk
21.1%
20%
Shellfish
17.2%
15% Tree Nut
13.1%
Egg
9.8%
10%
Fin Fish
6.2% Wheat Soy
5% 5.0% 4.6%
0%
___________________________________________________________________________________________________________________________________________
Gupta RS, SpringstonEE, WarrierMR, Smith B, Kumar R, PongracicJ, HollJL. The prevalence, severity, and distribution of 
childhood food allergy in the United States. Pediatrics 2011 Jul; 128(1):e9‐e17.
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Presenter: R. Gupta
Prevalence of Anaphylaxis
• “Studies found wide differences in the rates (from 
1/100,000 population to as high as 70/100,000 
population) of hospitalization or emergency 
department visits for anaphylaxis.”
• “The proportion of anaphylaxis cases thought to be 
due to foods varies between 13% and 65%.”
‐NIAID
___________________________________________________________________________________________________________________________________________
Boyce et al. “Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID‐Sponsored Expert Panel.” J Allergy ClinImmunol.
2010; 126: S11‐S12.
Presenter: R. Gupta
Prevalence of Food Allergies
Peanut Shellfish Tree Nut Milk Egg Wheat
0 –2 years
22.2 7.5 5.4 31.5 15.8 4.0
(n=5429)
3 –5 years
30.3 12.9 14.3 22.1 13.7 5.0
(n=5910)
6 –10 years
25.5 17.1 14.3 19.6 11.1 5.0
(n=9911)
11 –13 years
28.1 20.4 15.2 17.7 6.6 8.2
(n=6716)
14-17 years
20.2 23.8 13.4 18.4 4.1 3.3
(n=10 514)
___________________________________________________________________________________________________________________________________________
Gupta RS, SpringstonEE, WarrierMR, Smith B, Kumar R, PongracicJ, HollJL. The prevalence, severity, and distribution of 
childhood food allergy in the United States. Pediatrics 2011 Jul; 128(1):e9‐e17.
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Associations of Race & IncomPreesenter: R. Gupta
Black and Asian race Hispanic race Household income <$50k
• Higherodds of  • Lowerodds of being  • Lowerodds of having 
having a food allergy diagnosed by a  a food allergy 
(Black race OR=1.8;  physician  (OR=0.5)
Asian race OR=1.4) (OR=0.8) • Lowerodds of being 
diagnosed by a 
• But lowerodds of 
physician (OR=0.5)
being diagnosed by a 
physician
(Black race OR=0.8; 
Asian race OR=0.7) 
*All P<.05
Presenter: R. Gupta
Food Allergies Can Be Severe
39%
Children who have
experienced a
severe reaction
___________________________________________________________________________________________________________________________________________
Gupta RS, SpringstonEE, WarrierMR, Smith B, Kumar R, PongracicJ, HollJL. The prevalence, severity, and distribution of 
childhood food allergy in the United States. Pediatrics 2011 Jul; 128(1):e9‐e17.
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Presenter: R. Gupta
All Foods Cause Severe Reactions
60%
53% 53%
50%
47%
43%
41%
40% 38%
31% 30%
30%
20%
10%
0%
Tree nut Peanut Shellfish Soy Fin fish Wheat Milk Egg
Percentage of Food‐Specific Reactions classified as severe
___________________________________________________________________________________________________________________________________________
Gupta, RuchiS., et al. "The prevalence, severity, and distribution of childhood food allergy in the United States." Pediatrics128.1 (2011): e9‐e17.
Presenter: R. Gupta
Developing Tolerance to Food
• Tolerance: Individual is symptom free after consumption of 
the food or upon oral food challenge weeks, months, or even 
years after the cessation of treatment.
• Studies indicate that: 
– 82% of patients were tolerant to egg by age 16
– 69% of patients were tolerant to soy by age 10
– 65% of patients were tolerant to wheat by age 12
– 80% of patients were tolerant to milk by age 5
___________________________________________________________________________________________________________________________________________
Boyce et al. “Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID‐Sponsored Expert Panel.” J Allergy ClinImmunol.2010; 
126: S14‐S15.
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Presenter: R. Gupta
Comorbid Conditions
• Food allergic children are 2 to 4 times more 
likely than those without food allergies to 
have related conditions such as:
– Asthma (4.0 fold)
– Atopic dermatitis (2.4 fold)
– Respiratory allergies (3.6 fold)
___________________________________________________________________________________________________________________________________________
Boyce et al. “Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID‐Sponsored Expert Panel.” J Allergy Clin
Immunol.2010; 126: S16‐S18.
Geographic Variability Presenter: R. Gupta
Using the same data, described geographic variability in the US:
• North‐to‐South decline notobserved
• Odds of food allergy significantly higherat more southern and middle latitudes 
compared to northern states (OR 1.5, 95% CI 1.3‐1.8 & OR 1.3, 95% CI 1.1‐1.5)
___________________________________________________________________________________________________________________________________________
Gupta RS, SpringstonEE, Zhang XY, Smith B, WarrierMR, PongracicJ, HollJK. Geographic variability of childhood food allergy in the 
United States. ClinPediatr2012, May 17. [Epubahead of print].
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Geographic Variability Presenter: R. Gupta
Instead, population density corresponded with prevalence (P<.0001):
10
9.8%
9
9.2%
8
7.8%
7 7.6%
7.2%
6
6.2%
5
4
Urban Metro Urban Suburban Small Rural
Centers Cities Outskirts Areas Towns Areas
___________________________________________________________________________________________________________________________________________
Gupta RS, SpringstonEE, Zhang XY, Smith B, WarrierMR, PongracicJ, HollJK. Geographic variability of childhood food allergy in the 
United States. ClinPediatr2012, May 17. [Epubahead of print].
Presenter: R. Gupta
Economic Impact:
Total Annual Cost Total Annual Cost
per Child: In the U.S.:
$4,184 $24.8 billion
___________________________________________________________________________________________________________________________________________
Gupta RS, HoldfordD, BilaverL, Dyer A, Holl J, Meltzer D. The high economic impact of childhood food allergy in the United States. JAMA Pediatrics Sept 2013 16.
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Presenter: R. Gupta
High Cost of Food Allergies
Annual Costs, US$
95% CI
Characteristic Total  Per Child Total  Per Child
(in Billions) (in Billions)
Costs borne by families
Out‐of‐pocket  5.5 931 (4.7‐6.4) (793‐1080)
treatment
Lost laborproductivity 0.77 130 (0.53‐1.0) (89‐175)
Opportunity 14.2 2399 (10.5‐18.4) (1771‐3104)
Total
Reported costs borne by  20.5 3457 (16.7‐24.9) (2816‐4208)
families
Directmedical costs 4.3 724 (2.8‐6.3) (472‐1063)
Reported costs 24.8 4184 (20.6‐29.4) (3475‐4960)
Learning Objectives
• Definition & Epidemiology
• Physical Examination Clinical History
• Diagnostic Testing
• Food Allergy Management
– Epinephrine 
– Education
• Referral to an Allergist
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Presenter: J. Lee
Evaluating a child with symptoms
1. Is this an allergy or intolerance?
2. If this is a suspected allergy, it is IgE or non‐
IgE mediated?
3. If this is suspected IgE‐mediated reaction, 
then consider allergist referral and 
confirmation with allergy testing.
Presenter: J. Lee
Classification of Food Reactions
Adverse Food Reaction
Non-Immune
Immune Mediated
Mediated
Non-IgE Mixed IgE &
IgE Mediated
Mediated Non-IgE Mediated
Food Food
Unrelated Related
Adaptedfrom Fig 1 NIAID
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