Faculty Bibliography

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology (JCAAI). The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Food Allergy: A practice parameter update-2014." This is a complete and comprehensive document at the current time. The medical environment is a changing one, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, ACAAI, and JCAAI. These parameters are not designed for use by pharmaceutical companies in drug promotion.

BACKGROUND:Currently, there is no satisfactory treatment for IgE-mediated food allergy. Food Allergy Herbal Formula 2 (FAHF-2) and butanol-purified FAHF-2 (B-FAHF-2) have been shown to protect against peanut-induced anaphylaxis and inhibit IgE synthesis in a murine model. OBJECTIVE:To determine which herbs and compounds in FAHF-2 and B-FAHF-2 suppress IgE production. METHODS:The effect of FAHF-2 and B-FAHF-2 on IgE production was determined using a human B-cell line (U266). Individual compounds were isolated and identified using column chromatography, liquid chromatographic mass spectrometry, and nuclear magnetic resonance techniques. The potency of compounds on IgE suppression were investigated using U266 cells and verified using human peripheral blood mononuclear cells (n = 25) from peanut-allergic patients. Epsilon germline transcript expression was determined. Phosphorylated IκBα level was analyzed using the In-Cell Western assay. The mRNA expression of signal transducer and activator of transcription-3, T-box transcription factor TBX21, interferon-γ, forkhead box P3, GATA-binding protein 3, interleukin-10, and interleukin-5 also were analyzed using real-time polymerase chain reaction. RESULTS:FAHF-2 and B-FAHF-2 inhibited IgE production by U266 cells. B-FAHF-2 was 9 times more effective than FAHF-2. Two compounds that inhibited IgE production were isolated from Philodendron chinensis and identified as berberine and limonin. Berberine was more potent and inhibited IgE production by peripheral blood mononuclear cells by 80% at 0.62 μg/mL. Berberine significantly inhibited ε-germline transcript expression by peripheral blood mononuclear cells. Phosphorylated IκBα level was significantly suppressed and mRNA expressions of T-box transcription factor TBX21 and signal transducer and activator of transcription-3 were significantly increased by berberine. CONCLUSION/CONCLUSIONS:Berberine and limonin mediated IgE suppression. The mechanism by which berberine modulates ε-germline transcript expression might be through regulating the phosphorylated IκBα level and the expressions of signal transducer and activator of transcription-3 and T-box transcription factor TBX21. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov identifier NCT00602160.

CME EDUCATIONAL OBJECTIVES 1. Recognize manifestations, diagnosis, and management of food protein-induced enterocolitis syndrome (FPIES) in an outpatient setting. 2. Assess nutritional needs and provide anticipatory guidance for dietary management. 3. Recognize the indications of when to refer for assessment of resolution of FPIES using physician-supervised food challenges. Food protein-induced enterocolitis syndrome (FPIES) is an under-recognized non-immunoglobulin E (IgE)-mediated gastrointestinal food allergy affecting primarily infants and toddlers. An abnormal response to food antigen resulting in local inflammation is thought to lead to increased intestinal permeability and fluid shift. The primary features of acute FPIES are repetitive, projectile vomiting, lethargy, pallor, diarrhea, and dehydration. Chronic FPIES is typically seen in young infants with continued exposure to cow's milk or soy-based formula. Biomarkers are lacking and patients may undergo extensive workups for their symptoms, which often leads to a delay in diagnosis and puts infants at risk for feeding difficulties, nutritional deficiencies, and failure to thrive. This review will provide a guide in how to recognize the clinical features of and manage FPIES.

Although the need for nutritional and dietary intervention is a common thread in food allergy management, the type of food allergic disorder and the identified food allergen will influence the approach to dietary intervention. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. However, dietary elimination in food allergy may also have undesirable consequences. Frequently, an elimination diet is absolutely necessary to prevent potentially life-threatening food allergic reactions. Allergen elimination can also ease chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. However, removing a food with proven sensitivity to treat chronic symptoms may increase the risk of an acute reaction upon reintroduction or accidental ingestion after long-term avoidance, so it is not without risk. Additionally, it is not recommended to avoid foods in an attempt to control chronic symptoms such as AD and EoE when allergy to the specific food has not been demonstrated. Ultimately, allergen elimination goals are to prevent acute and chronic food allergic reactions in the least restrictive, but also the safest environment to supply a balanced diet that promotes health and growth and development in children.

In the past two decades, food allergy has emerged as an important public health issue in countries with a western life-style. Current management of food allergy relies on dietary avoidance and there is no therapy proven to restore permanent oral tolerance to food. This review focuses on novel approaches to allergen-specific therapy for IgE-mediated food allergy. Oral immunotherapy alone or in combination with anti-IgE antibody is likely to advance into clinical practice in the more immediate future. However, these approaches have to be further validated in large clinical trials before entering clinical practice. Diets containing extensively heated (baked) milk and egg for the majority of milk- and egg-allergic patients represent a safer alternative approach to food oral immunotherapy and are already changing the paradigm of strict dietary avoidance for majority of milk and egg-allergic children.