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Vincent R, MacNeill SJ, Marrs T, Craven J, Logan K, Flohr C, Lack G, Radulovic S, Perkin MR, Ridd MJ. Frequency of guideline-defined cow's milk allergy symptoms in infants: Secondary analysis of EAT trial data. Clin Exp Allergy 2022; 52:82-93. [PMID: 34877731 DOI: 10.1111/cea.14060] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/01/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-IgE-mediated Cow's Milk Allergy (CMA) has a prevalence of less than 1% in children. Guidelines developed to help non-specialists diagnose CMA may lead to misattribution of normal symptoms and contribute to overdiagnosis of CMA. We sought to establish the frequency of symptoms during infancy associated with non-IgE-mediated CMA, using the international Milk Allergy in Primary Care (iMAP) guideline as representative of CMA guidelines more generally. METHOD Secondary analysis of the Enquiring About Tolerance (EAT) randomized controlled trial (ISRCTN 14254740; 1303 exclusively breastfed 3-month-old healthy infants). Key outcomes were ≥2 iMAP symptoms associated with 'mild-moderate' and 'severe' non-IgE-mediated CMA. RESULTS Whilst breastfeeding and parental atopy rates were higher than the general population, participants were otherwise similar to the population of England and Wales. Two or more non-IgE CMA symptoms were reported by 25% families for mild-moderate and 1.4% for severe symptoms each month between ages 3 and 12 months, peaking at 38% with ≥2 mild-moderate and 4.3% ≥2 severe symptoms at three months, when participants were not directly consuming cow's milk. 74% of participants reported ≥2 mild-moderate symptoms and 9% ≥2 severe symptoms in at least one month during this period. At six months there was no evidence of difference in the proportion of children with ≥2 symptoms between those consuming (29.5% mild-moderate, 1.8% severe) and not consuming cow's milk (35.3% mild-moderate, 2.2% severe). Mean monthly reporting of ≥2 symptoms was also no different between those with (15.8% mild-moderate, 1.1% severe) or without eczema at baseline (16.7% mild-moderate, 1.3% severe). CONCLUSIONS Guideline-defined symptoms of non-IgE-mediated CMA are very common in infants. Guidelines may promote milk allergy overdiagnosis by labelling normal infant symptoms as possible milk allergy.
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Affiliation(s)
- Rosie Vincent
- Population Health Sciences, University of Bristol, Bristol, UK
- Dermatology, Bristol Royal Infirmary, University Hospital Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Stephanie J MacNeill
- Department of Medical Statistics, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Tom Marrs
- Department of Paediatric Allergy, Children's Allergies, Evelina London, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Department of Paediatric Allergy, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Kirsty Logan
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, Kings College London, London, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, St Thomas' Hospital, London, UK
| | - Gideon Lack
- Department of Paediatric Allergy, King's College London, London, UK
- Children's Allergy Clinical Academic Group, KHP Institute of Women and Children's Health at Evelina London, Guy's & St. Thomas' NHS Foundation Trust, London, UK
- Paediatric Allergy Group, Department of Women and Children's Health, Peter Gorer Department of Immunobiology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, St Thomas' Hospital, London, UK
| | - Suzana Radulovic
- Department of Paediatric Allergy, Children's Allergies, Evelina London, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Department of Paediatric Allergy, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Michael R Perkin
- Population Health Research Institute, St George's, University of London, London, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
- Department of Primary Health Care, Population Health Sciences, University of Bristol, Bristol, UK
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Babbel J, Ramos C, Wangberg H, Luskin K, Simon R. Adverse reactions to food additives. JOURNAL OF FOOD ALLERGY 2021; 3:8-23. [PMID: 39022633 PMCID: PMC11250194 DOI: 10.2500/jfa.2021.3.210004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Food additives are naturally occurring or synthetic substances that are added to food to modify the color, taste, texture, stability, or other characteristics of foods. These additives are ubiquitous in the food that we consume on a daily basis and, therefore, have been the subject of much scrutiny about possible reactions. Despite these concerns, the overall prevalence of food additive reactions is 1-2%, with a minority of the wide variety of symptoms attributed to food-additive exposure being reproduced by double-blind placebo controlled challenges. Reactions can be broadly classified into either immunoglobulin E (IgE)- and non-IgE-mediated reactions, with natural additives accounting for most IgE-mediated reactions, and both natural and synthetic additives being implicated in the non-IgE-mediated reactions. Reactions that include asthma exacerbations, urticaria and/or angioedema, or anaphylaxis with ingestion of a food additive are most deserving of further allergy evaluation. In this article, we discussed the different types of adverse reactions that have been described to various food additives. We also reviewed the specifics of how to evaluate and diagnose a food additive allergy in a clinic setting.
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Affiliation(s)
- Justin Babbel
- Scripps Clinic Department of Allergy and Immunology, San Diego, California
| | - Courtney Ramos
- Scripps Clinic Department of Allergy and Immunology, San Diego, California
| | - Hannah Wangberg
- Scripps Clinic Department of Allergy and Immunology, San Diego, California
| | - Kate Luskin
- Scripps Clinic Department of Allergy and Immunology, San Diego, California
| | - Ronald Simon
- Scripps Clinic Department of Allergy and Immunology, San Diego, California
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Andreozzi L, Giannetti A, Cipriani F, Caffarelli C, Mastrorilli C, Ricci G. Hypersensitivity reactions to food and drug additives: problem or myth? ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:80-90. [PMID: 30830065 PMCID: PMC6502174 DOI: 10.23750/abm.v90i3-s.8168] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK The possibility of an allergic reaction or an intolerance to additives is frequently suspected by parents, especially for chronic illness with frequent exacerbations such as atopic dermatitis or chronic urticaria. For more than 50 years, potential adverse reactions to additives have been suggested, but to date data are conflicting. The purpose of this article is to provide the clinicians with general information about additives and adverse reactions to them and to suggest a practical approach to children suspected to have reactions to food additives. METHODS We performed an extensive research on all English-language Medline articles, case reports and reviews published online until December 2018. Used search terms were: food additives, food dye, adverse reactions, food allergy, food hypersensitivity, intolerance, drugs, children. RESULTS There are only few case reports of adverse reactions in childhood with a clear involvement of additives. In this review article we reported the associations between additives and adverse reactions described in literature, in order to inform the pediatrician about the potential clinical manifestations. CONCLUSIONS Prior to suspect an adverse reaction to additives, it is important to rule out other possible causes: the diagnostic process is complicated and rarely conclusive. The gold standard is the double-blind placebo controlled oral challenge after an exclusion diet.
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Affiliation(s)
- Laura Andreozzi
- Pediatric Unit, Department of Medical and Surgical Sciences, University of Bologna, S. Orsola-Malpighi Hospital.
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Scientific Opinion on the appropriateness of the food azo-colours Tartrazine (E 102), Sunset Yellow FCF (E 110), Carmoisine (E 122), Amaranth (E 123), Ponceau 4R (E 124), Allura Red AC (E 129), Brilliant Black BN (E 151), Brown FK (E 154), Brown HT (E 155. EFSA J 2010. [DOI: 10.2903/j.efsa.2010.1778] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Affiliation(s)
- Cyrus Rangan
- Department of Adolescent Medicine, Childrens Hospital Los Angeles, Los Angeles, California, USA
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Benton D. The impact of diet on anti-social, violent and criminal behaviour. Neurosci Biobehav Rev 2007; 31:752-74. [PMID: 17433442 DOI: 10.1016/j.neubiorev.2007.02.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 02/02/2007] [Accepted: 02/16/2007] [Indexed: 11/27/2022]
Abstract
The role of diet in anti-social behaviour was considered, paying particular attention to double-blind placebo-controlled trials. Meta-analysis of five well-designed studies found that elimination diets reduced hyperactivity-related symptoms, producing a summary standardized mean difference (SSMD) of 0.80 (95% CI 0.41-1.19). The picture was of children potentially responding to a wide range of food items although the pattern was individual to the child. Supplementation with poly-unsaturated fatty acids decreased violence (SSMD -0.61, 95% CI -0.83 to -0.39) although there was no evidence of an influence on hyperactivity. Three well-designed studies have reported that vitamin/mineral supplementation reduced anti-social behaviour. There are also findings of an association between a tendency to develop low blood glucose and aggression. Many responses to diet were idiosyncratic and involved a wide range of foods interacting with individual differences in physiology. Reactions were not observed in all members of groups chosen because they share a common behavioural designation or diagnosis.
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Affiliation(s)
- David Benton
- Department of Psychology, University of Wales Swansea, Wales, UK.
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Inomata N, Osuna H, Fujita H, Ogawa T, Ikezawa Z. Multiple chemical sensitivities following intolerance to azo dye in sweets in a 5-year-old girl. Allergol Int 2006; 55:203-5. [PMID: 17075259 DOI: 10.2332/allergolint.55.203] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 11/29/2005] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cases of multiple chemical sensitivities (MCS) have been reported predominantly in adult patients, but pediatric cases have rarely been reported. METHODS We present a 5-year-old girl who suffered from recurrent reactions accompanied by urticaria, angioedema, headaches, dyspnea, loss of consciousness, and abdominal pain that were not eradicated, but were instead exacerbated, by various treatments with antihistamines and intravenous corticosteroids. Her diet diary revealed that symptoms occurred after ingestion of colorful sweets such as candies and jellybeans. Open challenge tests with food additives and nonsteroidal anti-inflammatory drugs (NSAIDs) were performed after elimination of these items. Skin prick tests using additives and NSAIDs, which were dissolved in saline, and prick- prick tests using candies and jellybeans, were carried out. RESULTS Open challenge tests with Tartrazine, aspirin and acetaminophen were positive, whereas skin prick tests using additives and NSAIDs and prick-prick tests using candies and jellybeans were all negative. Consequently, intolerance to azo dyes and NSAIDs such as aspirin was diagnosed. However, she appeared to react to multiple chemical odors such as those of cigarette smoke, disinfectant, detergent, cleaning compounds, perfume, and hairdressing, all while avoiding additives and NSAIDs. On the basis of her history and the neuro-ophthalmological abnormalities, a diagnosis of severe MCS was made and she was prescribed multiple vitamins and glutathione. CONCLUSIONS The present results suggest that in pediatric MCS, food and drug additives containing azo dyes might play important roles as elicitors.
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Affiliation(s)
- Naoko Inomata
- Department of Environmental Immuno-Dermatology, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.
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Abstract
OBJECTIVES To summarize the literature related to the classification of food additives and their reported adverse reactions and to provide a practical approach for evaluation of patients suspected of having such reactions. DATA SOURCES Information was derived from selected reviews and original articles published in peer-reviewed journals and from authoritative textbook chapters, supplemented by the clinical experience of the authors. STUDY SELECTION Priority was given to studies that used blinded, placebo-controlled oral challenges to confirm adverse reactions to food additives. In addition, selected, appropriately evaluated case reports are included. RESULTS A large number of food additives are widely used in the food industry. Adverse reactions to additives seem to be rare but are likely underdiagnosed in part due to a low index of suspicion. Numerous symptoms have been attributed to food additive exposure, but the cause-and-effect relationship has not been well demonstrated in all. CONCLUSIONS Reactions to food additives should be suspected in patients who report symptoms to multiple unrelated foods or to a certain food when commercially prepared but not when homemade and the allergy evaluation rules out a role for food protein. It is also prudent to investigate food additives in patients considered to have idiopathic reactions. There is a minor role for skin testing or in vitro testing. Oral challenge testing with common additives, preferably preceded by a trial of an additive-free diet, is the definitive procedure for detecting the offending agent. Once the specific additive is identified, management is basically avoidance of all its forms.
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Affiliation(s)
- Brian G Wilson
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71130-3932, USA
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Young E. Prevalence of intolerance to food additives. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 1997; 4:111-114. [PMID: 21781808 DOI: 10.1016/s1382-6689(97)10050-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Food additives have been implicated as aetiological factors in many different disease states. Concern arose from a suggested link with food additives and hyperactivity in children. They have also been implicated in many other disease states. This perception, often made by parents on behalf of their children, is not confirmed by double-blind placebo-controlled challenge studies. The discrepancy between public perception and the true prevalence of food additive reactions is great and this discrepancy between perception and confirmed reactions also exists with food-related symptoms. The discrepancy is much greater in the case of food additives than in foods. The mechanism of food additive reactions is not immunological and there is no in vivo or in vitro confirmatory test.
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Affiliation(s)
- E Young
- Department of Dermatology, Amersham General Hospital, Amersham, Bucks WHP7 0JB, UK
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