The Complete Guide to Food Allergies in Adults and Children

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Note to the Reader: This book is not meant to substitute for medical care, and treatment should not
be based solely on its contents. Instead, treatment must be developed in a dialogue between the
individual and their physician. Our book has been written to help with that dialogue.
Drug dosage: The author and publisher have made reasonable efforts to determine that the
selection of drugs discussed in this text conform to the practices of the general medical community.
The medications described do not necessarily have specific approval by the US Food and Drug
Administration for use in the diseases for which they are recommended. In view of ongoing research,
changes in governmental regulation, and the constant flow of information relating to drug therapy
and drug reactions, the reader is urged to check the package insert of each drug for any change in
indications and dosage and for warnings and precautions. This is particularly important when the
recommended agent is a new and/or infrequently used drug.

© 2022 Scott H. Sicherer, MD

All rights reserved. Published 2022
Printed in the United States of America on acid-free paper
987654321

Johns Hopkins University Press

2715 North Charles Street
Baltimore, Maryland 21218-4363
www.press.jhu.edu

Library of Congress Cataloging-in-Publication Data

Names: Sicherer, Scott H., author.

Title: The complete guide to food allergies in adults and children / Scott H. Sicherer, MD.
Description: Baltimore : Johns Hopkins University Press, 2022. | Series: A Johns Hopkins press
health book | Includes index.
Identifiers: LCCN 2021017979 | ISBN 9781421443164 (hardcover) | ISBN 9781421443157
(paperback) | ISBN 9781421443164 (ebook)
Subjects: LCSH: Food allergy. | Food allergy in children. | Food allergy—Treatment. | Food allergy—
Prevention. | Self-care, Health.
Classification: LCC RC596 .S378 2022 | DDC 616.97/5—dc23
LC record available at https://lccn.loc.gov/2021017979

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Contents
Preface
Introduction, by Hugh A. Sampson, MD

CHAPTER 1
Understanding Food Allergy and Intolerance
Food Allergy
Food Intolerance, Irritable Bowel Syndrome, and Celiac Disease
Food Allergy Symptoms and Illnesses
Severity
When Symptoms Are Not a Food Allergy
Masqueraders of Food Allergy
Prevalence of Food Allergies
Causes and Triggers of Food Allergies
Peanuts
Eggs
Cow’s Milk
Wheat and Other Grains
Tree Nuts
Seeds
Soy
Legumes
Vegetables and Starches
Fruits
Meats
Fish
Shellfish
Spices
Alcoholic Beverages
Miscellaneous Food Allergens and Colors, Additives, Preservatives, and
Latex
Case Studies

CHAPTER 2
When and How to Discuss a Possible Food Allergy Diagnosis with
Your Doctor
When to Talk to Your Doctor
How to Prepare for a Doctor Visit
Finding the Right Doctor and Other Health Professionals
Complementary and Alternative Therapies

CHAPTER 3
All about Allergy Tests
General Questions about Testing
Skin Tests
Blood Tests (and How They Compare with Skin Tests)
Component Tests / Molecular Diagnostics
Elimination Diets
Oral Food Challenges (Feeding Tests)
Additional Tests
Unproven and Disproven Tests
Improved Diagnostic Tests
Chapter Lessons

CHAPTER 4
Recognizing and Treating Anaphylaxis
General Questions about Anaphylaxis
Epinephrine
Antihistamines
Additional Medications and Treatments for Anaphylaxis
Written Emergency Plans, Education, Medical Identification Jewelry, and
Management Issues
Chapter Lessons
CHAPTER 5
Chronic Health Problems Caused by Food Allergy
General Questions about Chronic Illnesses and Foods
Respiratory Symptoms
Hives and Swelling
Atopic Dermatitis (Eczema)
Gastrointestinal and Digestive Illnesses
Colic, Constipation, and Reflux
Proctocolitis (Food Protein–Induced Proctocolitis)
Food Protein–Induced Enterocolitis Syndrome
Food Protein Enteropathy and Protein Intolerance
Eosinophilic Esophagitis and Other Eosinophilic Gut Diseases
Chronic Illnesses That Are Not Related to Food Allergies
Delving Deeper

CHAPTER 6
Mastering Allergen Avoidance
General Questions about Avoiding Allergic Reactions
Cross-Contact
Amounts That Trigger a Reaction and Casual Exposure
Avoidance at Home
Manufactured Products
Restaurants
Social Outings and Family Gatherings
School
Camp
Work
Travel
Dating and Relationships
Age-Related Responsibilities
Special Exposure Risks
Delving Deeper

CHAPTER 7
Maintaining Lifestyle and Quality of Life, Reducing Anxiety, and
Keeping a Healthy Diet
General Questions about Lifestyle and Quality of Life
Emotional Concerns and Anxiety
Interpersonal Relationships and Bullying
Nutrition
Chapter Lessons

CHAPTER 8
The Natural Course and Resolution of Food Allergies
General Questions about Food Allergy Resolution
The Course of Allergies to Specific Foods
The Course of Illnesses Caused by Food Allergies
Evaluations for Resolution of Food Allergy
Recurrence of a Food Allergy and Development of New Food Allergies
Factors Affecting the Course of Food Allergies
Delving Deeper

CHAPTER 9
Prevention of Food Allergies
General Questions about Risk Factors and Prevention Strategies
Pregnancy Diets
Breastfeeding and Formulas
Introducing Solid Foods
Current Recommendations
Nondietary Aspects of Prevention
Chapter Lessons

CHAPTER 10
The Future Is Now: Treatments for Food Allergy
General Questions about Food Allergy Research
Approaches to Treat Any Type of Food Allergy
Approaches to Treat Allergies to Specific Foods (Immunotherapies)
Treatments of Specific Food-Allergic Diseases
Unproven Treatments
Participating in Food Allergy Research

CHAPTER 11
Accessing Help and Information to Manage Food Allergies
Educational Resources
Resources for Managing Life with Food Allergies
Selected Internet Resources on Food Allergies
Support Groups, Advocacy, and Research
Handy Forms
Cited Medical References and Additional Articles of Interest

Index
Preface
This book is dedicated to people with food allergies and those who care for
them. It is the result of thousands of questions I have been asked by adults
and children with food allergies; parents of children with food allergies; as
well as allergists, medical students, physicians in training, pediatricians, the
media, government officials, researchers, teachers, school nurses, and
others. Your questions have led me at times to seek answers from you as
well as from others, from research, and through trial and error. It is my
pleasure and privilege to present this book, which is designed to give you
what you have asked for: a place to find accurate, timely, detailed, and
helpful answers to questions on every aspect of food allergies.
I marvel at the amazing strides I have witnessed in the diagnosis,
prevention, and treatment of food allergies, particularly over the past five
years. We now have tests that are better at diagnosing a true allergy, and
even better ones are on the way. We have gained insights on how food
allergy can be prevented, with a clear approach for peanut, and are in the
midst of multiple studies on preventing other food allergies. The first
therapy for food allergy approved by the US Food and Drug Administration,
a peanut oral immunotherapy product, has come into practice. In parallel,
oral immunotherapy approaches to other foods are under study and are also
being used in many practices. Numerous exciting novel approaches are also
under study, with increasingly better safety and efficacy. In this book, I
explore all of these areas to help you make informed decisions. While the
emerging therapies are presenting some difficult choices, they also offer a
remarkable number of options to treat food allergy and improve quality of
life. It is hard for me to imagine, based on what I see in this field, that we
will be doing what we are doing now in another five or ten years. I feel
confident in telling my young patients that when they are adults, they may
not need to avoid the foods they are allergic to today. Although most of the
approaches that are emerging are not a simple “cure,” I have strong hope
that we will get there.
 This book would not exist were it not for the work and influences of
many people, and so I dedicate this book to the many who have taught me
over the years, including Hugh A. Sampson, MD; Sally Noone, RN; Marion
Groetch, RD; and Robert A. Wood, MD. It is also dedicated to my many
colleagues at Mount Sinai’s Jaffe Food Allergy Institute, and researchers
and colleagues worldwide. I want to thank the National Institute of Allergy
and Infectious Diseases and Food Allergy Research & Education for
supporting my research. I thank the Jaffe family for their foresight in
establishing a food allergy institute at Mount Sinai in New York, and also
the many families and visionary philanthropists for supporting our research
and clinical care initiatives. Most importantly, I thank the children, adults,
and families who have altruistically contributed to our understanding of
food allergy by their participation in research studies—they are absolutely
the heroes who will help us to cure this disease. Finally, I thank my wife,
Mati, and children, Andrew, Zachary, Maya, Sydnee, and Cassaddee . . . for
everything.
Introduction
Hugh A. Sampson, MD
Emeritus Director, Jaffe Food Allergy Institute, Icahn School of Medicine at
Mount Sinai, New York

Over the past four decades, I have been fortunate to witness and participate
in a remarkable evolution in our understanding of food allergies. When I
began my food allergy research in the early 1980s, I approached the
disorder by applying my background in detailed scientific methods.
Although a bit reluctant and highly skeptical, I was encouraged to explore
this area by Dr. Susan Dees, an emeritus professor and a wonderful mentor
during my early years at Duke University. Then my own fascination with
the field grew as a result of experiences with my second daughter, who had
food allergies, eczema, and later asthma, and as I cared for an increasing
number of families and children with food allergy symptoms in my clinical
practice. In those early years, I was reluctant to admit to my colleagues that
I was focusing my research on food allergy. The reason for my trepidation
was that food allergy, in those early days, was considered not a “real
disease” but a problem of little consequence. Part of the reason for this
misperception was that many people were attributing various problems to
foods that were never proven to be involved using scientifically validated
methods. At the same time, people were not recognizing allergic diseases
that actually were caused or worsened by foods. Although everyone
acknowledged that a food could cause a severe allergic reaction, the life-
threatening nature of this allergy was not well appreciated.
In the mid-1970s, the food allergy field began to emerge from scientific
uncertainty in part because of the work of Drs. Charles May and Allan
Bock, who emphasized the need to use a diagnostic procedure called a
double-blind, placebo-controlled oral food challenge, which is discussed in
detail in this book. This test brought objectivity to the diagnosis of food
allergies by eliminating patients’ and physicians’ preconceived notions. In
my research work, the procedure fostered incredible scientific advances to
further improve the diagnosis and treatment of food allergies. Food allergy
became “real” and was now viewed as a medical illness worthy of attention
and acknowledged as a field of allergy in need of more research. Today,
food allergy has become a hot topic, and many programs around the world
are actively pursuing a better understanding of these disorders and effective
forms of prevention and therapy. This expanded involvement by the
scientific community has resulted in the topic of food allergy dominating
sessions and abstract presentations at international congresses held
throughout the world.
The emergence of food allergy from the “dark ages” into a time of
scientific exploration was exciting; however, the past decades have
unfortunately witnessed an alarming increase in food allergies and other
allergic diseases. All ages are affected. The burden of living with food
allergies remains largely untold and underappreciated. Those who are
allergic and their families must practice constant dietary caution and be at
the ready to treat severe allergic reactions. Despite increasing awareness,
this disease is still sometimes fatal.
The good news is that the past decade has witnessed a revolution in the
approach to food allergy. Diagnostics have improved to reduce the need for
oral food challenges. Proven approaches to preventing food allergy are in
practice with more to come. Multiple therapies are under study and in use,
including a first FDA-approved treatment. Amazing basic science advances
are leading the way to new and better modalities to predict, prevent, and
treat food allergy. The dizzying array of options and new approaches can be
confusing.
The explosion of information (and misinformation) about food allergy
has outpaced our ability to teach food allergy sufferers, parents, children,
and caregivers what we have learned and what they need to know. Being
unable to find reliable information with sufficient details about food
allergies leaves patients and their families feeling unfulfilled and confused.
They have many burning questions and concerns. We now have clear
answers for many of these concerns, and when the right answer is unclear,
we have plenty of information that can be helpful while research is
underway. Knowing the answers and understanding the issues behind what
we can and cannot yet answer are vital to working with your doctor,
discussing your or your child’s food allergy with others, and ultimately
obtaining the best care possible. This book is an encyclopedia of the
essential information you need to do this, and it is the only resource I know
of that provides timely, accurate, and accessible information on every
medical aspect of food allergy.
Dr. Scott Sicherer, an internationally recognized leader in food allergy
education and research, has culled nearly three decades of experience in
patient care and research to present this information in a readable and
understandable format. He provides both basic medical information and tips
on how to deal with everyday issues such as visiting the allergist; going to
school, work, and restaurants; and navigating the supermarket. Dr. Sicherer
has been at the cutting edge of clinical and social issues of food allergy. As
a lecturer, he has had countless discussions about food allergy experiences
with patients, parents, school nurses, camp directors, food service
professionals, pediatricians, internists, allergists, children, and many others.
He has distilled these experiences here to answer virtually every possible
question about food allergies, from questions you may have wondered
about to, even more importantly, many questions you should be asking.
The information in this book is so comprehensive and timely that it
should be required reading not only for adults with food allergies and
parents of children with food allergies, but also for physicians, teachers,
school nurses, camp personnel, spouses, and everyone who plays a role in
caring for those with food allergies. It will help them to understand and
more effectively and safely manage these allergies, and to understand
emerging treatment and prevention strategies. I certainly plan to keep a
copy in my clinic and to recommend it to the many people I encounter
whose lives are affected in some way by pervasive allergies to food.
The Complete Guide to
Food Allergies
in Adults and Children
CHAPTER 1

Understanding Food Allergy and

Intolerance

Food is our sustenance, but it can also make us sick in a variety of ways.
This chapter describes food allergy (a focus of this book), food intolerance,
and other ways that food can cause problems.

Food Allergy

What is a food allergy?

A food allergy happens when the immune system, a part of the body that
usually fights germs, attacks harmless proteins in foods.

How does the immune system “attack” proteins in foods?

Two ways: with cells that release various chemicals, and by producing
proteins called IgE antibodies.
What role do the IgE antibodies play in food allergy?
The most common forms of food allergy, when allergic reactions happen
suddenly after a food is eaten, are the result of the immune system making
IgE antibodies. These proteins are like small antennae that sit atop allergy
cells (called mast cells and basophils) and detect the food proteins. The IgE
“antennae” are able to detect a specific food protein, for example, a peanut
protein or an egg protein. When these IgE antibodies come in contact with
the food protein, they signal the allergy cells to release powerful chemicals,
such as histamine, which produce allergic symptoms.

How do cells in the immune system cause food allergies?

The cells respond to the food protein by releasing chemicals that cause
inflammation with persistent symptoms, such as rashes, or symptoms
affecting the gut, such as pain, nausea, and vomiting. The term “non-IgE-
mediated,” or “cell-mediated,” food allergy is used when the cells of the
immune system are causing allergic responses to foods without involving
IgE.

Other than food allergy, how might foods make a person sick?
A food can make a person ill in many ways. Food poisoning happens when
bacteria in spoiled food release toxins that can cause symptoms. Chemicals
in foods can cause symptoms in some people. For example, caffeine may
cause sweating, tremors, or heart palpitations. Food intolerance causes
some people to become ill from a food that does not trouble others.

At what age does a person develop a food allergy?

Any age. Food allergies most often develop in infancy and childhood,
however.

What are the most common triggers of food allergy in infants, children,
and adults?
For infants and children, cow’s milk, eggs, and peanuts are the most
common triggers, followed by tree nuts, shellfish, soy, wheat, and fish.
Adult-onset food allergy usually involves nuts, seafood, fruits, or
vegetables.

How do I know if I have a food allergy?

Specific symptoms after eating a food, or patterns of symptoms, are a good
clue that you may have a food allergy. These will be described below.

Food Intolerance, Irritable Bowel Syndrome, and Celiac Disease

What is a food intolerance?

Strictly speaking, “food intolerance” typically refers to trouble digesting
specific food ingredients because of deficiency in enzymes, resulting in
symptoms affecting the gut. But the terms “intolerance” and “sensitivity”
are often used to describe a host of problems experienced from foods that
are distinct from food allergy. In a broader sense, food intolerances or
sensitivities are terms often used to include not only problems with
digestion (the best example being lactose intolerance), but also irritable
bowel syndrome, problems caused by food additives, celiac disease, and
even stress-related problems associated with foods. While not usually
falling under the definition of “intolerance,” a person with gall bladder
disease may notice problems with fatty foods and consider themselves to be
“sensitive” to them. A person with gout may consider themselves sensitive
to certain meats and seafood, as they can contribute to the disease. Here we
discuss classical food intolerance and irritable bowel syndrome (IBS) and
celiac disease. Later in this chapter we review problems attributed to
chemical properties of foods and food additives.

What are differences between food allergy and intolerance?

Aside from the distinction that allergy involves the immune system and
intolerance does not (an exception is celiac disease, which is sometimes
called gluten-sensitive enteropathy), the symptoms differ in some ways but
can overlap. Typical symptoms of intolerance affect the gut (pain, vomit,
diarrhea). While food allergy symptoms may also involve the gut, they can
include life-threatening symptoms that affect breathing and blood
circulation as well. Another distinction is that many people with intolerance
can get by eating small or modest amounts of problem foods, while many
people with food allergies react to small amounts.

What is lactose intolerance?