Currently, the only way to manage FA is avoidance of the allergen and prompt treatment of symptoms when they arise. Accidental exposure to food allergens is inevitable and patient and family education regarding cross-contamination, label reading, and prompt recognition and treatment of food allergic reactions is a cornerstone of FA management. Because avoidance of specific allergens can limit the availability of nutritious food choices, nutritional counseling and regular growth monitoring are recommended for all children with FA, especially during infancy.
Elimination of causative foods should be minimized to prevent nutritional disorders and improve the quality of dietary life. Even if a food is positive for sIgE antibodies and skin prick test, it should not be eliminated if an oral challenge test is negative. Tolerance to foods, especially egg and milk, should be checked periodically, because children tend to outgrow the allergies. Strict avoidance of offending allergen-containing food products has been the standard of care for children with FA. However, as noted, Lemon-Mule et al.33)
have recently demonstrated that ingestion of extensively heated egg products was well-tolerated and safe for some patients with egg allergy, and they have suggested that strict dietary avoidance of heated egg might not be necessary for all patients with egg allergy.
Because even trace amounts of food allergens may trigger severe reactions in highly sensitive food-allergic individuals, strict avoidance is very important in these individuals. It is essential to educate patients and families regarding cross-contamination and label reading, because many patients and their caregivers do not recognize the risk of exposure to trace amounts of food allergen. In Korea, food labeling regulations announced by the Korean Food & Drug Administration (effective June 17, 2006) require food manufacturers to indicate if a product contains any of 12 food allergens: milk, eggs, peanuts, soy, wheat, buckwheat, shrimp, crab, mackerel, pork, tomato, and peach. However, this regulation is not sufficient to prevent FA accident because it excludes tree nut and fish, which are also important allergens that can cause anaphylaxis. Therefore, food labeling regulations need to be revised. Another danger faced by food-allergic patients is occult contamination with trace amounts of food from shared of equipment. All equipment and utensils used to prepare allergenic food should be cleaned with hot soapy water before being used to prepare allergen-free food.
The US NIAID guidelines recommend nutritional counseling and regular growth monitoring for all children with FA. Children with FA may be at risk for inadequate nutritional intake or poor growth without apparent nutritional problems35
. Flammarion et al.37)
assessed food intake and nutritional status of children (mean age, 4.7±2.5 years) with FA following an elimination diet and reported that children with food allergies were smaller for their age than controls, even when they received similar nutrients. Young children who are sensitive to multiple major food allergens are at risk for protein and calorie deficiency and may require a hypoallergenic formula to meet their needs. Hypoallergenic formulas available in Korea are based on extensively hydrolyzed casein derived from cow's milk (i.e., Babywell HA, Pregestimil, Neutramigen, Alimentum) or on a mixture of single amino acids (Neocate). Soy protein formula is not an appropriate substitute for patients with cow milk allergy because soy allergy is highly prevalent in patients with cow milk allergy38
. Sheep and goat milk-based formulas are also discouraged because of cross-reactivity with cow milk28)
Children may be at risk for accidental exposure to food allergens and FA reactions, including anaphylaxis, in schools and daycares, where they spend many of their days. In Korea, 99.6% of all schools provide school lunches, and 8 million students, representing approximately 20% of the Korean population, are offered school lunches during school days40)
. Presently, most students with FA must rely solely on self-care, because no emergent measures for FA provided by the schools are in place. Other developed countries, including the US and Japan, have introduced school-wide or government-supported plans for management FA in schools41
. Government-supported management and treatment action plans for FA at schools should also be established in Korea.
For families of patients in the US with FA who need practical information and a comprehensive curriculum regarding FA management, www.foodallergy.org
provides advice on dietary avoidance, along with survival strategies for schools, restaurants, and camps, manufacturers' updates, and special support programs for teenagers and FA experts43)
. In Korea, www.foodallergy.or.kr
supplies food allergic families and supervisors with similar information.
In summary, FA is an emerging worldwide health problem requiring increased attention from primary care clinicians in Korea. Although FA has a relatively low mortality and an almost continual absence of physical symptoms, patients with FA face the possibility of potentially severe, and even fatal, reactions and must maintain dietary vigilance. It is essential to offer information and support to children with FA and their families. General practitioners should tailor this information to the specific needs of each FA patient and parents and pediatricians should be aware of psychosocial problems in children with allergic diseases.