Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists

Shared decision-making in food allergy: Navigating an exciting era

OBJECTIVE

Shared decision-making (SDM) is increasingly used in food allergy. We review its use in the areas of prevention, diagnosis, and management.

DATA SOURCES

PubMed and online SDM resources.

STUDY SELECTIONS

Studies and reviews relevant to SDM and areas in food allergy that decision-making may be applied were selected for discussion.

RESULTS

Food allergy represents an area with multiple opportunities for SDM. Patients, on one hand, need to obtain the necessary information and understanding of existing options from the allergist. The allergist, on the other hand, needs to understand "where the patient is coming from," their needs, preferences, and values, so that jointly they can reach a decision that is responsive to these. Benefits of SDM include a better understanding of disease by patients, improved compliance with medication, better health outcomes, decreased health care costs, and improved ability of patients to manage their disease and make informed choices.

CONCLUSION

In food allergy prevention, diagnosis, and management, multiple preference-sensitive options exist for patients where SDM may be used during allergy consultations, alongside decision aids. Decision aids are tools that assist and support patients during the SDM process, by supplementing the patient-physician interaction.

A review of food allergy panels and their consequences

Serum immunoglobulin E (IgE) assays to food specific IgE (s-IgE) are useful tools for the confirmation of clinical suspicion of food allergy. However, the specificity of these assays is poor given that sensitization is much more common than clinical food allergy. Therefore, the use of broad panels to assess sensitization to multiple foods often leads to overdiagnosis and unnecessary food avoidance. Unintended consequences that may occur as a result include physical harm, psychological harm, financial cost, opportunity cost, and even worsening of existing health care disparities. Although current guidelines recommend against the use of s-IgE food panel testing, these tests are widely available and frequently used. To limit the negative impacts of s-IgE food panel testing, further work is needed to effectively spread the message that these food panels may cause unintended harm to patients and families.

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Gastrointestinal Food Allergies and Intolerances

Adverse reactions to food include immune-mediated food allergies, celiac disease, and nonimmune-mediated food intolerances. Differentiating between these many disorders is important to guide us toward appropriate testing and management. Double-blind placebo-controlled food challenges are the gold standard for food allergy diagnosis but are difficult and time-consuming. In place of this, strong clinical history, other supportive tests, and oral food challenges are helpful. Some commonly available tests for food allergy and intolerances lack sufficient evidence for efficacy. Food intolerance diagnosis is largely based on history and supported by symptom improvement with appropriate dietary manipulation.

Does Provider Specialty Matter?

OBJECTIVES

Multiple practice guidelines discourage indiscriminate use of broad panels of allergen-specific IgE (sIgE) tests due to increased risk of false positives and misinterpretation of results. We provide an analytical framework to identify specialty-specific differences in ordering patterns and effectiveness, which can be used to improve test utilization.

METHODS

Test results from a tertiary pediatric hospital were analyzed by ordering specialty to evaluate size of allergen workups. Positivity rates were analyzed to determine effectiveness in selecting tests with high positive pretest probabilities. Laboratory test menu components were also evaluated.

RESULTS

Our findings demonstrate 29% of sIgE tests are ordered as part of broad workups (>20 sIgE tests/date of service) contrary to the recommended testing approach. Detailed descriptions of ordering patterns and positivity rates are provided.

CONCLUSIONS

This study provides a framework for using a cross-sectional analytical approach to assess test utilization patterns and evaluate components of laboratory testing menus.

Unproven Diagnostic Tests for Food Allergy

The gold standard for diagnosis of immunoglobulin E (IgE)-mediated food allergy remains the oral food challenge, with serum IgE testing and skin prick testing serving as acceptable alternatives. However, the increase in prevalence of food allergy (both physician diagnosed and patient suspected) has led patients to pursue a variety of other alternative diagnostic procedures for suspected food allergy, which are reviewed in this article. These procedures (IgG testing, electrodermal testing, cytotoxic testing, provocation/neutralization, and applied kinesiology) have largely been unproven and may lead to unnecessary elimination diets.

Translational Education

The issue of translational education of healthcare professionals is a major one. It is clear that a great degree of upskilling is already required and, to keep pace with the science, this must be ongoing. Stakeholders need to achieve this together - with agreed-on standards across the board so that no patient is denied a suitable, virtually tailor-made treatment due to a lack of knowledge or understanding on behalf of the healthcare professional treating and diagnosing him or her. A key partner in tackling this is the healthcare community, and one way to achieve the goal is through increased EU-wide investment in translational education and training of healthcare professionals.

What is new in managing patients with food allergy? Almost everything

PURPOSE OF REVIEW

This review aims to describe current concepts in managing patients with food allergy. There have been many recent advances in the management of patients with IgE-mediated reactions to food, including diagnosis, prevention, management, and ongoing research in the field. Food allergy is increasing in prevalence and may be life threatening. This review aims to highlight changes in recommended practice when diagnosing and managing patients with food allergy.

RECENT FINDINGS

Early introduction of highly allergenic foods, particularly peanut, has been shown to decrease the risk for development of food allergy in patients who are at elevated risk. Avoidance of foods without a clinical history of food allergy may increase the risk of subsequent allergy. Epinephrine remains the first line therapy for anaphylaxis, and patients and families need to be instructed on indications and technique for use. Promising research is ongoing in areas of immunotherapy to food allergens.

SUMMARY

Food allergy is a potentially life-threatening condition that may persist throughout adulthood. Practitioners should be aware of changes to recommendations for the diagnosis, prevention, and management of patients with food allergy.