Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Food Allergy
Under the Auspices of the
IAP Action Plan 2022
Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Lead Author
IAP President-Elect 2022 Jaidev MD
Piyush Gupta Co-Authors
IAP President 2021
Uppin Narayan Reddy, Vikram Patra
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
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Food Allergy

Food hypersensitivity (adverse reaction to food) is the umbrella term which refers to any
Introduction

untoward reaction following ingestion of food (Flowchart 1).

The term “food allergy” refers to “an adverse health effect arising from a specific immune
response that occurs reproducibly on exposure to a given food”.
Food intolerances are nonimmune reactions. These may occur in response to exposure to
metabolic substances (lactose intolerance), toxins (microbial contamination or scombroid
fish poisoning), and pharmacologically active components (caffeine and tyramine in aged
cheese triggering migraine).

Types of Food Hypersensitivity

Flowchart 1: Different types of food hypersensitivity.

(IgE: immunoglobulin E)
 Food Allergy

Major Allergens
Major allergens most commonly responsible for significant reactions include milk, egg,
peanut, tree nuts, shellfish, fish, wheat, and soya. In India, lentils, chickpea (Cicer arietinum),
and other legumes allergies are observed.

Clinical presentation differs in various forms of food allergies. Broadly food allergies are
differentiated as immunoglobulin E (IgE)-mediated, non-IgE-mediated, and mixed type.
Symptomatology ranges from isolated gastrointestinal symptoms in mild cases to multisystem
involvement in moderate-to-severe forms. Nongastrointestinal organs commonly involved are
skin, respiratory, and cardiovascular system.

TABLE 1: Presentations of different types of food hypersensitivity (FHS).

Gastrointestinal Cutaneous Respiratory Generalized
Immunoglobulin Oral allergy syndrome, Urticaria Acute Anaphylaxis, food-
E (IgE)-mediated gastrointestinal Angioedema rhinoconjunctivitis, dependent exercise-
Presentation

food allergy anaphylaxis acute asthma induced anaphylaxis

(FDEIA)
Non-IgE-mediated Food protein-induced Contact Heiner’s syndrome
food allergy (cell- proctocolitis, food dermatitis (food-induced
mediated FHS) protein-induced pulmonary
enterocolitis, food hemosiderosis)
protein-induced
enteropathy
IgE- and/or non- Allergic eosinophilic Atopic Asthma
IgE-mediated (cell- esophagitis, allergic dermatitis
mediated) eosinophilic
gastroenteritis
Non-allergic food Lactose intolerance,
hypersensitivity pharmacological
reactions caused by
caffeine (jitteriness),
tyramine in aged
cheese (migraine)

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 Food Allergy

TABLE 2: IgE-mediated and non-IgE-mediated reactions.

Characteristics IgE mediated Non-IgE mediated
History
;; Onset of symptoms Usually within 30 minutes (within 2 Generally hours or days after
hours of ingestion) ingestion

Presentation
;; Symptoms seen ;; Gastrointestinal: Vomiting, crampy Often nonspecific symptoms. These
pain, and diarrhea include:
;; Skin: Urticaria, angioedema, and ;; Diarrhea
pruritus ;; Vomiting
;; Respiratory: Acute ;; Colic/pain
rhinoconjunctivitis, coughing, ;; Blood in stool
wheezing, and stridor ;; Gastroesophageal reflux
;; Cardiovascular: Collapse as a ;; Food refusal/aversion
consequence of hypotension
Tests ;; Serum-specific IgE (RAST) Elimination diet for 2–6 weeks
;; Skin prick tests followed by reintroduction
;; Food challenges (symptoms recur)
(IgE: immunoglobulin E; RAST: radioallergosorbent test)

A reliable and good allergy focused history in combination with positive skin prick test (SPT)
is required for diagnosis of IgE-mediated food allergy. In vitro test like serum-specific IgE
against specific food allergen is advised where SPT is contraindicated or cannot be performed.
Diagnosis

A positive allergy test (SPT or food-specific IgE) alone signifies sensitization and not allergy.
So, these tests in isolation without a supporting clinical history cannot be used for definitive
diagnosis of food allergy.
Newer investigations like component resolved diagnosis (CRD) are now available to
detect hypersensitivity to specific component of the allergen. This may help differentiate
hypersensitivity due to cross reactive proteins from true allergy.
In cases of diagnostic uncertainty and in non-IgE-mediated food allergies, double-blinded
placebo control oral food challenge is the gold standard and should only be attempted in an
observed hospital setting with prior consent.

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 Food Allergy

;; Strict avoidance of the offending food is the best, simplest, and the safe way to avoid
allergic reactions.
;; Patient and family education including recognition of an allergic reaction, careful
attention to food labels before consumption, care when obtaining food from restaurants,
and avoidance of cross contamination of allergenic foods during meal preparation.
Management

;; Providing families with individualized allergy management plans and patient-specific

emergency medications (adrenaline: prefilled syringe or autoinjector) in the event of an
anaphylaxis.
;; “More active approach” which includes:
•• Early dietary food introduction: Early introduction of peanut (before 11 months of
age) to infants is associated with reduced risk of peanut allergy [Learning Early About
Peanut allergy (LEAP) study].
•• Active anticipatory testing: Testing for co-allergens which are commonly found to
be present in association with the suspected allergen. For example, in children with
peanut allergy, testing for tree nuts and sesame is recommended as the estimated rate
of co-allergy is 30–40% and 25%, respectively. This approach of anticipatory testing
may help in avoiding unnecessary restrictions in diet, may prevent development of
allergy to co-allergens by early introduction in the diet.

;; Newer strategies: Following therapies are practiced, if the offending food cannot be avoided
or chances of accidental consumption present which can lead to fatal reactions.

Newer Strategies
•• Desensitization—oral immunotherapy (OIT): Food OIT (concentrated on cow’s milk,
egg, and peanut) involves administration of small but increasing doses of allergenic food
to children who are allergic to that particular food in an effort to increase their clinical
tolerance. Risk of serious systemic and gastrointestinal reactions is the key limitation.
Desensitization can also be done by sublingual immunotherapy (SLIT) but the challenge
threshold and sustained unresponsiveness achieved is less as compared to OIT though
systemic and local adverse reactions are less common.
•• Early introduction of baked milk/egg: It has been observed that 70–75% of children
with cow’s milk and egg allergies can tolerate them when extensively heated. This could
potentially make dietary restrictions easier and hasten the development of tolerance,
although it remains difficult to predict which children will tolerate baked allergens.

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 Food Allergy

;; Mother should consume normal and balanced diet without any restrictions of allergenic
foods during pregnancy and lactation. No strong evidence to support role of omega-3
long-chain polyunsaturated fatty acids (LCPUFA), vitamin D, and folate/folic acid
Preventing Food Allergy

supplementation during pregnancy, to prevent allergies in offspring.

;; Exclusive breastfeeding till 6 months of age.
;; Introduce complementary foods (solids) as pureed foods by offering small amounts of
vegetables, fruits, starchy foods, and protein. Never add salt or sugar.
;; Inclusion foods associated with food allergies that are a part of family’s diet, e.g., wheat,
egg, fish/seafood, foods containing peanut and tree nuts, etc., during age-appropriate
complementary feeding.
;; Aim to introduce these foods before 12 months of age, but one new food at a time.
;; Continue to give the baby these foods regularly as part of their usual diet, unless not
tolerated as this may help reduce the chance of developing an allergy to that food later.
;; Never give whole or coarsely chopped nuts as these are a choking risk.
;; No recommendations at present, for use of probiotics during pregnancy, lactation,
and after birth to infants. Role of partially or extensively hydrolyzed formula and use of
emollients as skin barriers in preventing food allergies in infants is not clear.

;; Anagnostou K, Stiefel G, Brough H, du Toit G, Lack G, Fox AT. Active management of food allergy: an
emerging concept. Arch Dis Child. 2015;100:386-90.

Further Reading
;; British Society for Allergy & Clinical Immunology (BSACI). (2018). Preventing food allergy in high risk
infants: guidance for health care professionals. [online] Available from [Link]
content/uploads/2020/02/pdf_Early-[Link] [Last accessed January, 2022].
;; Devdas JM, Mckie C, Fox AT, Ratageri VH. Food Allergy in Children: An Overview. Indian J Pediatr.
2018;85(5):369-74.
;; Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomised trial of peanut
consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-13.
;; Lerodiakonou D, Garcia-Larsen V, Logan A, Groome A, Cunha S, Chivinge J, et al. Timing of allergenic
food introduction to the infant diet and risk of allergic or autoimmune disease. A systematic review
and meta-analysis. JAMA. 2016;316(11):1181-92.