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## Complete Summary

#### GUIDELINE TITLE

Paediatric food hypersensitivity and allergy.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Paediatric food hypersensitivity and
allergy. In: EBM Guidelines. Evidence-Based Medicine \[Internet\].
Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Apr
10 \[Various\]. \[13 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Food hypersensitivity and allergy. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2006 Dec 13 \[Various\].

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Food hypersensitivity and allergy

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Allergy and Immunology\
Family Practice\
Internal Medicine\
Nutrition\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Dietitians\
Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given
recommendations.

#### TARGET POPULATION

Children at risk for and with known food hypersensitivity and allergy

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention**

1.  Identification of risk groups and preventative measures

2.  Exclusive breast feeding for at least 4 to 6 months

3.  Partially hydrolysed formulas

**Note**: Guideline developers considered but did not recommend maternal
antigen avoidance during lactation to prevent atopic eczema in the child
and maternal avoidance of food allergens during pregnancy to prevent
atopic manifestations in the infant.

**Diagnosis/Evaluation**

1.  Evaluation of signs and symptoms of food allergy

    -   Gastrointestinal signs and symptoms

    -   Cutaneous eruptions

    -   Exacerbation of asthma

2.  Diagnosis of food hypersensitivity

    -   Allergy history

    -   Suspicion of previous anaphylaxis

    -   Elimination and reintroduction trials

**Management**

1.  Elimination of foods

2.  Referral to pediatric specialist care

3.  Growth monitoring

4.  Vaccination considerations

5.  Re-evaluation of diet over time

**Note**: Guideline developers discussed but did not specifically
recommend skin or blood testing, skin prick tests, and patch or
epicutaneous tests.

#### MAJOR OUTCOMES CONSIDERED

-   Allergy prevalence

-   Incidence of atopic conditions

-   Adverse effects of dietary antigen avoidance on maternal and fetal
    nutrition

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the Database of Abstracts of Reviews of
Effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Classification of the Quality of Evidence**

+----+------------+----------------------------------------------------+
| ** | **Quality  | **Definition**                                     |
| Co | of         |                                                    |
| de | Evidence** |                                                    |
| ** |            |                                                    |
+====+============+====================================================+
| *  | **High**   | Further research is very unlikely to change our    |
| *A |            | confidence in the estimate of effect.              |
| ** |            |                                                    |
|    |            | -   Several high-quality studies with consistent   |
|    |            |     results                                        |
|    |            |                                                    |
|    |            | -   In special cases: one large, high-quality      |
|    |            |     multi-centre trial                             |
+----+------------+----------------------------------------------------+
| *  | **         | Further research is likely to have an important    |
| *B | Moderate** | impact on confidence in the estimate of effect and |
| ** |            | may change the estimate.                           |
|    |            |                                                    |
|    |            | -   One high-quality study                         |
|    |            |                                                    |
|    |            | -   Several studies with some limitations          |
+----+------------+----------------------------------------------------+
| *  | **Low**    | Further research is very likely to have an         |
| *C |            | important impact on confidence in the estimate of  |
| ** |            | effect and is likely to change the estimate.       |
|    |            |                                                    |
|    |            | -   One or more studies with severe limitations    |
+----+------------+----------------------------------------------------+
| *  | **Very     | Any estimate of effect is very uncertain.          |
| *D | Low**      |                                                    |
| ** |            | -   Expert opinion                                 |
|    |            |                                                    |
|    |            | -   No direct research evidence                    |
|    |            |                                                    |
|    |            | -   One or more studies with very severe           |
|    |            |     limitations                                    |
+----+------------+----------------------------------------------------+

GRADE (Grading of Recommendations Assessment, Development and
Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial
Team).

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence \[A-D\] supporting the recommendations are
defined at the end of the \"Major Recommendations\" field.

-   Food hypersensitivity includes both food allergy and food
    intolerance.

-   In food allergy, the symptoms are related to an immunological
    mechanism. A skin-prick test or tests for specific immunoglobulin E
    (IgE) antibodies in the serum may be used in the determination of an
    immunological mechanism.

-   Most infants suffering from food allergy to nutritionally important
    foods (milk, cereals) recover at pre-school age.

-   School-aged children may develop allergy to vegetables or fruit.

**Epidemiology**

-   Up to half of the parents of children younger than 2 years of age
    associate some of the child\'s symptoms with food, however, most
    suspicions of allergy dissolve with time (Eggesbo et al., 1999).

-   In a survey of school children, 24% reported to be or to have been
    allergic to food at some point (Csonka et al., 2000).

**Prevention**

-   To prevent allergies, the risk groups should be identified reliably,
    and an efficient preventative measure should be available (Csonka et
    al., 2000).

-   Maternal antigen avoidance during lactation has no effect on the
    incidence of atopic eczema in the child according to one small study
    (Kramer & Kakuma, 2006) \[**D**\].

-   Maternal avoidance of food allergens during pregnancy (third
    trimester) does not prevent atopic manifestations in the infant
    (Kramer & Kakuma, 2006) \[**C**\].

-   All studies concerning prevention have been carried out in children
    at high risk of atopy, and the evidence has been reviewed to be of
    poor quality (Brand, Vlieg-Boerstra, & Dubois, 2007).

-   Exclusive breast feeding for at least 4 to 6 months is recommended,
    but the allergy-preventing effect of this is modest at best (Kramer
    & Kakuma, 2002).

-   Partially hydrolysed formulas are effective when breast-feeding is
    not available for high-risk infants (at least one first-degree
    relative with correctly diagnosed allergy) (Baumgartner et al.,
    1998; Osborn & Sinn, 2003) \[**A**\]. These products may not be
    marketed in all countries.

**Causes of Food Allergy**

-   In principle any food can cause allergy. There is no allergy-safe
    diet.

-   If a baby does not eat a particular food substance, he/she cannot
    become sensitised to it. He/she also cannot develop tolerance to it.

-   See the Finnish Medical Society Duodecim guideline \"How to
    Investigate Symptoms Associated with Foods?\"

**Cow\'s Milk and Cereal Allergies**

-   Nutritionally most significant (Räsänen & Ylönen, 1992)

-   Mainly seen in young children

-   Rarely after pre-school age

-   Symptoms caused by these foods usually appear in infancy soon after
    the food has been introduced to the child\'s diet.

-   See the Finnish Medical Society Duodecim guideline \"Cow\'s Milk
    Allergy.\"

**Allergens Related to Birch Pollen Allergy**

-   Allergens associated with birch pollen allergy include the
    following:

    -   Root vegetables: potato, carrot, celery, parsnip

    -   Fruit and other vegetables: apple, pear, peach, kiwi fruit,
        plum, mango, tomato, sweet pepper

    -   Spices: mustard, caraway, turmeric, ginger, cinnamon

    -   Others: walnut, almond

-   In most cases preparation of vegetables (cutting, freezing, and
    especially cooking) removes the allergenicity, the majority of
    persons allergic to birch pollen can eat cooked vegetables.

-   After pre-school age, the avoidance of allergens should be based on
    symptoms, not test results. Due to cross-reactions, the number of
    false-positive results is high in skin-prick and radioallergosorbent
    test (RAST) testing, and they are therefore not recommended.

**Other Allergens**

-   Peanuts, soya, fish, shellfish, eggs, wheat, barley, oats, rye,
    buckwheat, banana, avocado

-   Linseeds, sesame seeds and poppy seeds

-   Mushrooms, especially shiitake

-   Causes of intolerance (no allergy mechanism)

    -   Strawberry, citrus fruit, chocolate, tomato

-   Alcoholic drinks

    -   Cereal allergens, aniseed, colouring agents, metabisulphite,
        benzoic acid

**Anaphylactic Reaction**

-   May, in theory, occur with any food

-   In infants with milk and egg allergy

-   Possible allergens both in children and adults: fish, shellfish,
    peanuts, soya, celery, kiwi fruit, linseeds and sesame seeds

**Symptoms of Food Allergy**

-   Typically several symptoms are manifested: stomach pain, diarrhoea,
    cutaneous eruptions, etc.

-   In 50% to 80% of infants admitted to hospital with atopic eczema
    (i.e., with severe eczema, a food allergy is found to aggravate the
    symptoms) (Isolauri & Turjanmaa, 1996).

-   Atopic eczema can also be exacerbated by air-borne allergens: birch
    pollen in the spring, grass pollen suspended in water and contact
    with pets (eczema in areas exposed to air is suggestive).

-   Eczema can also occur in contact areas (touching a dog, peeling
    potatoes).

-   Of gastrointestinal symptoms, the most obvious one is contact
    allergy around the mouth and lips which appears almost immediately
    after ingestion and is easy to connect with the food (tomatoes,
    citrus fruit and apples in those allergic to birch pollen).

-   Other symptoms that appear soon after ingestion of the food (loose
    stools, vomiting) are also rather easy to connect with the allergen,
    especially if the association occurs repeatedly.

-   Delayed gastrointestinal reactions, or worsening of the atopic
    eczema, are very difficult to associate with a particular food.

-   The frequency of bowel motions varies greatly between individuals.
    For example, in infancy defecation 10 times a day or once a week may
    be normal (provided that the child is well and developing normally).

-   All changes in the diet can cause temporary changes in bowel
    function, as can courses of antibiotics.

**Other Symptoms**

-   Food hypersensitivity may also be linked to exacerbation of asthma.

-   There is no evidence supporting an association between food
    (hypersensitivity) and migraine, arthritis, cystitis or nephritis.

**Diagnosis of Food Hypersensitivity**

-   See also the Finnish Medical Society Duodecim guidelines \"Cow\'s
    Milk Allergy\" and \"How to Investigate Symptoms Associated with
    Foods\" (\"Food allergy in children,\" 2005; Vandenplas et al.,
    2007).

-   As a basic rule, skin or blood testing of older children for food
    hypersensitivity should be avoided unless there is a strong
    suspicion.

-   The diagnosis should be based on elimination and reintroduction
    trials (see clinical algorithm, \"Diagnostic work-up of food
    allergy\" in the original guideline document). For the nutritionally
    important foods (milk and wheat in young children) a more formal
    elimination-challenge test should be carried out (e.g., in the
    fashion described below).

    -   The suspected food(s) are eliminated from the diet totally (for
        1 to 2 weeks).

    -   The onset/disappearance of symptoms is recorded in a symptom
        diary.

    -   Reduction or disappearance of symptoms supports food allergy,
        but is not diagnostic. The food needs to be reintroduced
        (challenge).

    -   A small amount of the food is reintroduced to the diet and, as
        long as the child remains asymptomatic, the amount is increased
        gradually to the normal (age-adjusted) amount consumed daily.

    -   Symptoms usually reappear within a week (symptom diary) after
        consuming large enough amounts.

-   History reveals immediate reactions. Foods that are nutritionally
    less important need not be tested but can be eliminated from the
    diet and reintroduced at a later stage.

-   Suspicion of anaphylactic reactions caused by food: careful analysis
    of the causative factor. NEVER instruct the patient to reintroduce
    the suspected food at home.

-   Positive skin prick tests or the presence of specific IgE antibodies
    are not enough for a diagnosis. IgA and IgG antibodies are detected
    in everyone and are not useful in diagnostics.

-   Patch or epicutaneous test is a method used in scientific research
    with selected patients in specialist settings. It is not a routine
    test method.

**Follow-Up**

-   Specific items of food that are not nutritionally important may be
    eliminated when the association between the symptoms and food is
    clear. Elimination reintroduction can be carried out at home whilst
    keeping a symptom diary.

-   There are no adequate trials on how these children should be
    followed up. Clinical experience therefore dictates the routines.

-   Indications for referral to specialist care

    -   An infant with widespread eczema or worsening symptoms

    -   An infant with difficult or perplexing symptoms, and the parents
        are convinced of food allergy

    -   Failure to thrive

    -   Diet limited by the parents to dangerously few foods

    -   An older child needs to be referred if the diet threatens to
        become too limited

-   In primary care

    -   The growth of a child on an elimination diet is monitored by
        growth charts.

    -   Vaccinations are given according to the normal programme.
        Allergy to eggs does not prevent vaccination unless the child
        has had an anaphylactic reaction to eggs (Aickin, Hill, & Kemp,
        1994).

    -   The family is encouraged to expand and rationalise the diet
        towards a normal diet.

    -   The child\'s diet should be re-evaluated at 5 years of age at
        the latest: is the avoidance of certain foods based on an
        elimination-challenge test? Should a specialist re-evaluate the
        situation?

    -   All elimination diets at school-age should be based on an
        established diagnosis.

**Related Resources**

Refer to the original guideline document for related evidence, including
Cochrane reviews and other evidence summaries.

**Definitions**:

**Classification of the Quality of Evidence**

+----+------------+----------------------------------------------------+
| ** | **Quality  | **Definition**                                     |
| Co | of         |                                                    |
| de | Evidence** |                                                    |
| ** |            |                                                    |
+====+============+====================================================+
| *  | **High**   | Further research is very unlikely to change our    |
| *A |            | confidence in the estimate of effect.              |
| ** |            |                                                    |
|    |            | -   Several high-quality studies with consistent   |
|    |            |     results                                        |
|    |            |                                                    |
|    |            | -   In special cases: one large, high-quality      |
|    |            |     multi-centre trial                             |
+----+------------+----------------------------------------------------+
| *  | **         | Further research is likely to have an important    |
| *B | Moderate** | impact on confidence in the estimate of effect and |
| ** |            | may change the estimate.                           |
|    |            |                                                    |
|    |            | -   One high-quality study                         |
|    |            |                                                    |
|    |            | -   Several studies with some limitations          |
+----+------------+----------------------------------------------------+
| *  | **Low**    | Further research is very likely to have an         |
| *C |            | important impact on confidence in the estimate of  |
| ** |            | effect and is likely to change the estimate.       |
|    |            |                                                    |
|    |            | -   One or more studies with severe limitations    |
+----+------------+----------------------------------------------------+
| *  | **Very     | Any estimate of effect is very uncertain.          |
| *D | Low**      |                                                    |
| ** |            | -   Expert opinion                                 |
|    |            |                                                    |
|    |            | -   No direct research evidence                    |
|    |            |                                                    |
|    |            | -   One or more studies with very severe           |
|    |            |     limitations                                    |
+----+------------+----------------------------------------------------+

GRADE (Grading of Recommendations Assessment, Development and
Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial
Team).

#### CLINICAL ALGORITHM(S)

The clinical algorithm \"Diagnostic work-up of food allergy\" is
provided in the original guideline document.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12792)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are. The type of supporting
evidence is identified and graded for select recommendations (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate diagnosis and management of food hypersensitivity and
    allergy in children

-   Prevention of food hypersensitivity and allergy in children

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Paediatric food hypersensitivity and
allergy. In: EBM Guidelines. Evidence-Based Medicine \[Internet\].
Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Apr
10 \[Various\]. \[13 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Sep 15 (revised 2008 Apr 10)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Minna Kaila

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Food hypersensitivity and allergy. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2006 Dec 13 \[Various\].

#### GUIDELINE AVAILABILITY

This guideline is included in \"EBM Guidelines. Evidence-Based
Medicine\" available from Duodecim Medical Publications, Ltd, PO Box
713, 00101 Helsinki, Finland; e-mail: <info@ebm-guidelines.com>; Web
site: [www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 29, 2005. This summary
was updated by ECRI on February 27, 2007. This summary was updated by
ECRI Institute on September 27, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008