Food for Thought: Guidance on Food Allergy

November 24, 2014

Food for Thought: Guidance on Food Allergy

  1. Mark V. Dahl, MD

An updated practice parameter on diagnosis and management, with a focus on children

  1. Mark V. Dahl, MD

The three main allergy associations commissioned a practice parameter update on food allergy, diagnosis, and management. The 13-member task force considered results of impactful studies, guidelines, clinical reports, and meta-analyses. They graded each reference for overall strengths of recommendation (SOR) and level of evidence (LOE). Food allergy was defined as adverse health effects arising from specific immune responses occurring reproducibly on exposure to a given food. Some relevant summary statements for dermatologists were:

  • A high proportion of food allergy is caused by relatively few allergens (cow's milk, hen's egg, soy, wheat, peanuts, tree nuts, fish, shellfish). (SOR strong; LOE B)

  • Evaluate patients with latex allergy for possible cross-reactivity to banana, avocado, kiwi, chestnut, potato, green pepper, and other fruits and nuts. (SOR strong, LOE C)

  • For infants with family history of atopy, consider partially or extensively hydrolyzed infant formula to prevent atopic dermatitis. (SOR moderate, LOE B)

  • Do not routinely recommend that patients with chronic idiopathic urticaria avoid foods containing additives. (SOR strong, LOE B)

  • Use prick tests and/or serum tests for specific immunoglobulin E (IgE) to diagnose food allergy; testing should be focused on suspected foods and test results alone should not be considered diagnostic. (SOR strong, LOE B)

  • Do not routinely obtain total IgE levels to diagnose food allergy. (SOR strong, LOE C)

  • Unproved tests (allergen-specific IgG measurement, cytotoxicity assays, applied kinesiology, provocation neutralization, hair analysis) should not be used to diagnose food allergy. (SOR strong, LOE C)

  • Routine use of atopy patch tests to diagnose food allergy is not recommended, except in conjunction with pediatric eosinophilic esophagitis evaluation. (SOR moderate, LOE C)

  • Recommend a nutritionist consult for growing children, as elimination diets might affect growth. Be aware of nutritional consequences of elimination diets, including deficiencies of vitamins C and D. (SOR strong, LOE B)


Self-reported food allergy is more common than proven food allergy. Food allergy is more common in children than adults, and among children, more common in those with other atopic diseases (atopic dermatitis, asthma, allergic rhinitis). Cutaneous reactions to foods include IgE-mediated reactions (urticaria, angioedema, flushing, pruritus), cell-mediated reactions (contact dermatitis, dermatitis herpetiformis), and mixed reactions (atopic dermatitis). The authors cite evidence that food allergy may be a “significant trigger” for atopic dermatitis in 30% to 40% of infants and children. In my view, this number is too high.

Editor Disclosures at Time of Publication

  • Disclosures for Mark V. Dahl, MD at time of publication Consultant / Advisory board Makucell, Inc.; Castle Diagnostics, Inc.; Up To Date; Ulthera, Inc.; Biohealth, Inc. Equity Elorac, Inc.; Makucell, Inc. Editorial boards UpToDate


Reader Comments (1)

Mervyn Garrett MBBS FACNEM Physician, Allergy/Immunology, ret

In over 40 years in a referred clinic I cannot remember a paediatric eczema where milk was not involved (mostly non IgE FA). Other common offenders are chocolate (cause of depigmentation and generally as Pit. alba) eggs citrus and tomato soy. It is a multifactorial disease yet there continue to be reports eliminating single factors-that are useless for interpretation. Each factors importance varies in each patient and also at any point in time in that patient, eg stress in a teenager would demand more attention. My experience also indicates that those milk affected infants who react on breast milk alone will also have beef and gelatine sensitivity. In one memorable case just the addition of probiotics made enormous difference with the ability to again tolerate the proven offending food.

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