Mandatory labeling of products with top allergens has improved food safety for consumers. Precautionary allergen labeling (PAL), such as "may contain" or "manufactured on shared equipment," are ...voluntarily placed by the food industry.
To establish knowledge of PAL and its impact on purchasing habits by food-allergic consumers in North America.
Food Allergy Research & Education and Food Allergy Canada surveyed consumers in the United States and Canada on purchasing habits of food products featuring different types of PAL. Associations between respondents' purchasing behaviors and individual characteristics were estimated using multiple logistic regression.
Of 6684 participants, 84.3% (n = 5634) were caregivers of a food-allergic child and 22.4% had food allergy themselves. Seventy-one percent reported a history of experiencing a severe allergic reaction. Buying practices varied on the basis of PAL wording; 11% of respondents purchased food with "may contain" labeling, whereas 40% purchased food that used "manufactured in a facility that also processes." Twenty-nine percent of respondents were unaware that the law requires labeling of priority food allergens. Forty-six percent were either unsure or incorrectly believed that PAL is required by law. Thirty-seven percent of respondents thought PAL was based on the amount of allergen present. History of a severe allergic reaction decreased the odds of purchasing foods with PAL.
Almost half of consumers falsely believed that PAL was required by law. Up to 40% surveyed consumers purchased products with PAL. Understanding of PAL is poor, and improved awareness and guidelines are needed to help food-allergic consumers purchase food safely.
Allergy to cow's milk is the most common food allergy in infants and it is usually outgrown by 5 years of age. In some individuals it persists beyond early childhood. Oral immunotherapy (OIT, oral ...desensitization, specific oral tolerance induction) has been proposed as a promising therapeutic strategy for persistent IgE-mediated cow's milk allergy. We previously published the systematic review of OIT for cow's milk allergy (CMA) in 2010 as part of the World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines.
To systematically synthesize the currently available evidence about OIT for IgE-mediated CMA and to inform the updated 2022 WAO guidelines.
We searched the electronic databases including PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations. We included all studies irrespective of the language of the original publication. The last search was conducted in February 2021. We registered the protocol on Open Science Framework (10.17605/OSF.IO/AH2DT).
We identified 2147 unique records published between 2010 and 2021, including 13 randomized trials and 109 observational studies addressing cow's milk OIT. We found low-certainty evidence that OIT with unheated cow's milk, compared to elimination diet alone, increased the likelihood of being able to consume ≥150 ml of cow's milk in controlled settings (risk ratio (RR): 12.3, 95% CI: 5.9 to 26.0; risk difference (RD): 25 more per 100, 95% CI 11 to 56) as well as accidently ingest a small amount (≥5 ml) of cow's milk (RR: 8.7, 95% CI: 4.7 to 16.1; RD: 25 more per 100, 95% CI 12 to 50). However, 2–8 weeks after discontinuation of a successful OIT, tolerance of cow's milk persisted in only 36% (range: 20%–91%) of patients. OIT increased the frequency of anaphylaxis (rate ratio: 60.0, 95% CI 15 to 244; rate difference 5 more anaphylactic reactions per 1 person per year, 95% CI: 4 to 6; moderate evidence) and the frequency of epinephrine use (rate ratio: 35.2, 95% CI: 9 to 136.5; rate difference 268 more events per 100 person-years, 95% CI: 203 to 333; high certainty). OIT also increased the risk of gastrointestinal symptoms (RR 6.9, 95% CI 1.6–30.9; RD 28 more per 100, CI 3 to 100) and respiratory symptoms (RR 49.0, 95% CI 3.12–770.6; RD 77 more per 100, CI 62 to 92), compared with avoidance diet alone. Single-arm observational studies showed that on average 6.9% of OIT patients (95% CI: 3.8%–10%) developed eosinophilic esophagitis (very low certainty evidence). We found 1 trial and 2 small case series of OIT with baked milk.
Moderate certainty evidence shows that OIT with unheated cow's milk in patients with IgE-mediated CMA is associated with an increased probability of being able to drink milk and, at the same time, an increased risk of serious adverse effects.
Background Allergen exposure at lung and gut mucosae can lead to aberrant TH 2 immunity and allergic disease. The epithelium-associated cytokines thymic stromal lymphopoietin (TSLP), IL-25, and IL-33 ...are suggested to be important for the initiation of these responses. Objective We sought to investigate the contributions of TSLP, IL-25, and IL-33 in the development of allergic disease to the common allergens house dust mite (HDM) or peanut. Methods Neutralizing antibodies or mice deficient in TSLP, IL-25, or IL-33 signaling were exposed to HDM intranasally or peanut intragastrically, and immune inflammatory and physiologic responses were evaluated. In vitro assays were performed to examine specific dendritic cell (DC) functions. Results We showed that experimental HDM-induced allergic asthma and food allergy and anaphylaxis to peanut were associated with TSLP production but developed independently of TSLP, likely because these allergens functionally mimicked TSLP inhibition of IL-12 production and induction of OX40 ligand (OX40L) on DCs. Blockade of OX40L significantly lessened allergic responses to HDM or peanut. Although IL-25 and IL-33 induced OX40L on DCs in vitro , only IL-33 signaling was necessary for intact allergic immunity, likely because of its superior ability to induce DC OX40L and expand innate lymphoid cells in vivo. Conclusion These data identify a nonredundant, IL-33–driven mechanism initiating TH 2 responses to the clinically relevant allergens HDM and peanut. Our findings, along with those in infectious and transgenic/surrogate allergen systems, favor a paradigm whereby multiple molecular pathways can initiate TH 2 immunity, which has implications for the conceptualization and manipulation of these responses in health and disease.
The first source was a random sample of the Canadian population (recruited through the SCAAALAR Surveying Canadians to Assess the Prevalence of Common Food Allergies and Attitudes towards Food ...Labelling and Risk SCAAALAR study, as previously described).6 If any household member had a convincing history of an IgE-mediated reaction to peanut, tree nut, or sesame or a physician's diagnosis of these allergies, the household was included as part of the directly affected population. Subjects with peanut, tree nut, and sesame allergy were also recruited from food allergy advocacy associations (Anaphylaxis Canada, Allergy/Asthma Information Association, and Association Quebecoise des Allergies Alimentaires) if they self-reported a convincing history of an IgE-mediated food allergy or a physician's diagnosis of food allergy.2 Households indirectly affected by food allergy were recruited from a single source, the SCAAALAR study.
Educational materials are needed to support parent management of and coping with childhood food allergy.
To evaluate whether a food allergy handbook can improve parental knowledge, confidence, and ...quality of life associated with the management of food allergy.
Participants included 153 parents of children diagnosed as having food allergy within the past 12 months who were recruited from hospital-based allergy clinics and food allergy organizations. Parents were randomly assigned to receive the food allergy handbook either after a baseline survey (handbook group) or at the conclusion of study participation (control group). Outcomes were assessed using online surveys at baseline, 2-week follow-up, and 2-month follow-up.
Compared with parents in the control group, parents in the handbook group had significantly greater improvement in knowledge at the 2-week (mean difference, 2.92; 95% confidence interval CI, 2.20-3.64; P < .001) and 2-month (mean difference, 2.46; 95% CI, 1.68-3.25; P < .001) follow-ups, significantly greater improvement in confidence at the 2-week (mean difference, 0.24; 95% CI, 0.09-0.39; P = .002) and 2-month (mean difference, 0.47; 95% CI, 0.30-0.63; P < .001) follow-ups, and significantly greater improvement in quality of life at the 2-month follow-up (mean difference, -0.48; 95% CI, -0.79 to -0.16; P = .004). Parents reported satisfaction with the content the handbook, with mean ratings of individual sections ranging from 2.7 to 3.2 on a 0- to 4-point scale and modal ratings of 3 (very useful).
The food allergy handbook evaluated in this study is an effective parent resource to supplement physician management of food allergy.
clinicaltrials.gov Identifier: NCT01914978.
Background Food-induced anaphylaxis is often a severe allergic reaction characterized by multiorgan dysfunction and a potentially fatal outcome. Objectives We sought to investigate the relative ...contribution of immunoglobulin-dependent effector pathways to anaphylactic responses to food (ie, peanut). Methods Wild-type and various mutant mice were sensitized with peanut protein and cholera toxin by means of oral gavage weekly for 4 weeks. Mice were subjected to different cellular depletion and Fc receptor blocking strategies before challenge with peanut 1 week after the last sensitization. Results Our data indicate that pathways other than the classical mast cell (MC)–IgE pathway contribute to the full spectrum of anaphylactic reactions to peanut. We show that the single deletion of MCs, basophils, or phagocytes (ie, macrophages) prevents the most significant clinical outcome: death. Remarkably, the combined deficiency of MCs and phagocytes, but not MCs and basophils, averted nearly all clinical and physiological signs of anaphylaxis. Furthermore, blockade of both IgE and IgG1 signaling was necessary to abolish anaphylactic responses to peanut. Although MC responses occurred through IgE and IgG1, phagocyte responses were fully mediated through IgG1. Conclusions Peanut-induced anaphylaxis is a process that involves the concerted action of multiple immune effector pathways, and thus interventions targeting a single pathway (eg, MC-IgE) might not be sufficient to fully prevent anaphylactic responses.
Background Food anaphylaxis is an acute and life-threatening systemic allergic reaction. Fatality registries place peanut as the most common culprit of fatal and near-fatal reactions in North ...America. Because prophylaxis and treatment have advanced little in recent years, it is imperative to evaluate novel therapies. Objective To investigate the impact of blocking mast cell mediators in a mouse model of peanut-induced anaphylaxis. Methods Mice were sensitized with peanut protein and cholera toxin via oral gavage weekly for 4 weeks. One week after the last sensitization, separate groups of mice were treated with either a (1) 5-lypoxygenase inhibitor, (2) a platelet-activating factor (PAF) receptor antagonist, (3) histamine receptor antagonists, or (4) a PAF receptor antagonist along with histamine receptor antagonists before peanut challenge. Results Treatment targeting either leukotrienes or histamine alone had no beneficial effects. In contrast, PAF antagonism significantly attenuated the magnitude and duration of the anaphylactic reactions. Particularly, it prevented severe reactions. Moreover, 83% of PAF-treated versus 43% of untreated mice reached recovery within 120 minutes after peanut challenge. Notably, combined blockade of PAF and histamine had a clearly greater beneficial effect. In fact, all but 1 mouse developed mild, if any, anaphylactic reactions. In addition, combination therapy was associated with a significant decrease in vascular leakage and release of vasoactive mediators after peanut challenge. Conclusion Combination therapy blocking both PAF and histamine markedly reduces the severity of peanut-induced anaphylaxis, and thus it may be a potential life-saving therapeutic approach in peanut and, likely, other food-induced anaphylaxis.
Little is known about the impact of food labeling on the allergic consumer.
To determine the proportion of food-allergic individuals attributing an accidental exposure to inappropriate labeling, ...failure to read a food label, or ignoring a precautionary statement and to identify factors associated with accidental exposures.
Food-allergic individuals or their caregivers were recruited from a Canadian registry of individuals with a physician-confirmed diagnosis of peanut allergy and from allergy awareness organizations. Participants completed questionnaires regarding accidental exposures due to specific food labeling issues. The association between accidental exposures and characteristics of food-allergic individuals or their caregivers was estimated using multivariate logistic regression models.
Of 1,862 potential participants, 1,454 (78.1%) responded. Of the 47.8% (95% confidence interval CI, 45.1%-50.5%) of respondents who experienced an accidental exposure, 47.0% (95% CI, 43.1%-50.9%) attributed the event to inappropriate labeling, 28.6% (95% CI, 25.1%-32.2%) to failure to read a food label, and 8.3% (95% CI, 6.3%-10.7%) to ignoring a precautionary statement. Food-allergic individuals who were allergic to peanut, tree nut, fish, or shellfish were less likely to experience an accidental exposure due to the allergen not being identified in plain language.
A considerable proportion of accidental exposures are attributed to inappropriate labeling, failure to read labels, and ignoring precautionary statements. Clear and consistent labeling of food allergens combined with increased consumer education is necessary to improve consumer confidence and compliance and to reduce accidental exposures.
Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of ...severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit.
These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA.
WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders.
After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.
The issued recommendations are labeled as “conditional” following the GRADE approach due to the very low certainty about the health effects based on the available evidence.
If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers’ values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.
