B. J. Vlieg-Boerstra

EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy

Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunologys (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence‐based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non‐life‐threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines.

Prevalence of food allergy and intolerance in the adult Dutch population

The prevalence of food allergy and intolerance (FA/FI) was studied in a random sample (n = 1483) of the Dutch adult population. First, the self-reported FA/FI reactions were investigated by questionnaire. Subsequently, in a clinical follow-up study, it was determined in how many cases this self-reported FA/FI could be objectively confirmed by double-blind placebo-controlled food challenge. More than 10% of the population (12.4%) reported FA/FI to specific food(s). Of the 144 subjects potentially available for the clinical follow-up study, 73 completed the whole protocol. In 12 subjects FA/FI could be confirmed by double-blind placebo-controlled food challenge. This indicates a minimum prevalence of FA/FI in the population of 0.8% (12 of 1483). Assuming that FA/FI is equal among participants, nonparticipants, and dropouts, the prevalence of FA/FI in the Dutch adult population is estimated to be 2.4%. The food (ingredients) involved included pork, white wine, and menthol. Two persons reacted to additives. In three persons glucose intolerance was observed. However, these specific intolerances probably do not reflect the distribution in the general population because the study population formed an extremely heterogeneous group, both with regard to the offending foods and the symptoms. The majority of the subjects had no serious complaints that required medical advice. We conclude that there is a gap between self-reported FA/FI and FA/FI that can be objectively confirmed by double-blind placebo-controlled food challenge.

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence‐based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life‐threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First‐line treatment for anaphylaxis is intramuscular adrenaline. Useful second‐line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high‐flow oxygen, intravenous fluids, inhaled short‐acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto‐injector. If an adrenaline auto‐injector is prescribed, education on when and how to use the device should be provided. Specialist follow‐up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.

The epidemiology of food allergy in Europe: a systematic review and meta-analysis

Food allergy (FA) is an important atopic disease although its precise burden is unclear. This systematic review aimed to provide recent, up‐to‐date data on the incidence, prevalence, time trends, and risk and prognostic factors for FA in Europe. We searched four electronic databases, covering studies published from 1 January 2000 to 30 September 2012. Two independent reviewers appraised the studies and qualified the risk of bias using the Critical Appraisal Skills Programme tool. Seventy‐five eligible articles (comprising 56 primary studies) were included in a narrative synthesis, and 30 studies in a random‐effects meta‐analysis. Most of the studies were graded as at moderate risk of bias. The pooled lifetime and point prevalence of self‐reported FA were 17.3% (95% CI: 17.0–17.6) and 5.9% (95% CI: 5.7–6.1), respectively. The point prevalence of sensitization to ≥1 food as assessed by specific IgE was 10.1% (95% CI: 9.4–10.8) and skin prick test 2.7% (95% CI: 2.4–3.0), food challenge positivity 0.9% (95% CI: 0.8–1.1). While the incidence of FA appeared stable over time, there was some evidence that the prevalence may be increasing. There were no consistent risk or prognostic factors for the development or resolution of FA identified, but sex, age, country of residence, familial atopic history, and the presence of other allergic diseases seem to be important. Food allergy is a significant clinical problem in Europe. The evidence base in this area would benefit from additional studies using standardized, rigorous methodology; data are particularly required from Eastern and Southern Europe.

The epidemiology of anaphylaxis in Europe: a systematic review

Anaphylaxis is an acute, potentially fatal, multi‐organ system, allergic reaction caused by the release of chemical mediators from mast cells and basophils. Uncertainty exists around epidemiological measures of incidence and prevalence, risk factors, risk of recurrence, and death due to anaphylaxis. This systematic review aimed to (1) understand and describe the epidemiology of anaphylaxis and (2) describe how these characteristics vary by person, place, and time.

Health-related quality of life of food allergic patients: comparison with the general population and other diseases

To cite this article: Flokstra‐de Blok BMJ, Dubois AEJ, Vlieg‐Boerstra BJ, Oude Elberink JNG, Raat H, DunnGalvin A, Hourihane JO’B, Duiverman EJ. Health‐related quality of life of food allergic patients: comparison with the general population and other diseases. Allergy 2010; 65: 238–244.

Development and validation of a self-administered Food Allergy Quality of Life Questionnaire for children

Background Having a food allergy may affect health‐related quality of life (HRQL). Currently, no validated, self‐administered, disease‐specific HRQL questionnaire exists for children with food allergy.

The diagnosis of food allergy: a systematic review and meta-analysis

We investigated the accuracy of tests used to diagnose food allergy.

Primary prevention of food allergy in children and adults: systematic review.

Food allergies can have serious physical, social, and financial consequences. This systematic review examined ways to prevent the development of food allergy in children and adults.

Management of anaphylaxis: a systematic review

To establish the effectiveness of interventions for the acute and long‐term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi‐randomized controlled trials, controlled clinical trials, controlled before–after studies and interrupted time series and – only in relation to adrenaline – case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty‐five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1‐antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long‐term management interventions studied were anaphylaxis management plans and allergen‐specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom‐triggered anaphylaxis.