UMC Pulmonary and Allergy Division

Pulmonary and Allergy Division

The Food Allergy Clinic opened its doors in April 2004. It is hosted by the Pulmonary/Allergy Division of the Department of Child Health at the University of Missouri-Columbia.The services provided by the Pulmonary/Allergy Division include the evaluation and management of the following conditions:

Respiratory Diseases, such as asthma, cystic fibrosis, bronchopulmonary dysplasia, invasive and non-invasive ventilation, etc.
Repiratory Allergy, including allergic asthma, hay fever, rhinoconjuctivitis, and others.
Allergic Disorders, such as food allergy, skin allergy, medication allergy.
Immunodeficiencies: evaluation of patients with recurrent and frequent infections.
Sleep-Disordered Breathing.

More specifically, the Food Allergy Clinic evaluates and manages different disorders associated to reactions to foods, including:

Anaphylaxis and other immediate reactions to food ingestion.
Delayed food reactions, including abdominal pain, reflux, vomiting, constipation, and diarrhea.
Eczema. Young children quite frequently have food allergies which worsen their eczema.
Eosinophilic gastrointestinal disorders which are relatively rare conditions manifested by vomiting, chest or abdominal pain, and/or diarrhea.
And other conditions associated with foods.

There is a list of links on the left side of the screen. These links will take you to other areas of our site that explain in more detail the what, how, why, and when of food allergy evaluation and management. There is a page providing several links to other food allergy associations that have valuable information that may be of interest. If you have any questions, you may reach us by phone or e-mail (displayed on the "About Us" link).

DISCLAIMER (nowadays this is a must in medicine-related sites): The information here displayed is with the intent to provide you with general information, it is NOT to be used to evaluate, diagnose, and treat or manage medical conditions. All actions should be coordinated and specified by a doctor trained on the specific medical conditions.

Reactions to foods are very common, but not all reactions to foods are allergic in nature

Food reactions are designated as "Adverse Food Reactions" (ADR), and there are several types of ADR:

Enzymatic Deficiency
- Lactase deficiency: Abdominal distension and increased "gas" associated with drinking milk. Those individuals lack the enzyme to digest lactose (sugar of the milk).
- Other conditions where enzymes are absent or not produced, such as cystic fibrosis, galactosemia, phenylketonuria, glucose-6-phosphate dehydrogenase deficiency.
Pharmacologic
- Caffeine: drinking too much coffee, soda (and even chocolate) can cause a rapid heart beat.
- Alcohol: Is getting drunk an allergic reaction or just an adverse reaction?
- Other substances: such as histamine, tyramine, theophylline, etc.
Structural
- Tracheoesophageal Fistula: a communication between the esophagus and the trachea.
- Hiatal Hernia: When the lower esophagus or the stomach itself herniates (passes through) the esophageal hiatus into the chest.
- Pyloric Stenosis: narrowing of a section of the gut.
Psychological
- Food Aversions: Have you watched those TV programs where somebody vomits after eating something very strange (bugs, worms, etc)?
- Food Phobias
Toxic
- Bacterial Toxins: Botulism toxin.
- Pesticides.
- Heavy Metals.
- Preservatives.
Infections
- Bacterial: E. coli, Salmonella sp, Campylobacter jejuni.
- Viral: enteroviruses (hepatitis).
- Fungal.
- Parasitic: Giardia sp, hookworms.
Immunologically Mediated. This section covers food allergy (discussed below).

So, as you can see, not all reactions are allergic. By far, most of the reactions are not allergic. Some studies quote that 25% of the adult population believe that they have a food allergy, but when properly studied only 2-3% (at most) have a real food allergy. The vast majority have an ADR. People might state that they are allergic to milk if they get abdominal pain, bloating, and diarrhea after drinking it; but these symptoms are relieved if they replace the enzyme they are lacking (lactase). This is why a complete assessment is needed in order to call an ADR a food allergic reaction. Of note, children have a higher incidence of food allergy than adults (6-8% vs. 2-3%).

The food allergic reactions are mediated by immunological mechanisms. These mechanisms are very complex, but for practical purposes they have been divided in three types:

mediated by immunoglobulin E (IgE)
mediated by cellular mechanisms (T-cells)
mixed reactions: IgE and T-cells

Below is an example of the conditions that are mediated by certain immunologic mechanims. The bi-directional arrow indicates that there is a continuum (spectrum) of these reactions.

T-cell	Mixed	IgE

Food Protein-induced Enterocolitis	Eosinophilic Esophagitis	Food Anaphylaxis
Food Protein-induced Proctitis	Eosinophilic Gastroenteritis	Oral Allergy Syndrome
Food Protein-induced Enteropathy	Eosinophilic Gastritis	Immediate Hypersensitivity
	Celiac Disease

In addition to the diseases mentioned above, there are many other conditions associated with foods where an immunological mechanism is thought to be a central player in at least some cases, such as gastroesophageal reflux, abdominal pain, colics, constipation, diarrhea, urticaria, angioedema, pulmonary bleeding, and other disorders.

In order to make a definitive diagnosis, your doctor needs to obtain a detailed history, perform a physical examination, and run a few tests that will lead to the specific diagnosis and hence an appropriate treatment.

A few pearls

All foods are capable of producing an allergic reaction.
In the majority of cases, food proteins are responsible for the reaction, rather than carbohydrates (sugars) or fats.
While there are some individuals allergic to many foods, the vast majority are allergic to one or a few from a common and short list.
The most common foods implicated in food allergy are: milk, egg, peanuts, nuts, soy, wheat, and fish.
Most children with a positive skin test and specific IgE to a food will not have a reaction if they eat that food. For example if someone has a positive skin test and also an elevated IgE to peanut, that does not necessarily mean that he/she is allergic to peanuts.
Food allergies can develop to foods that an individual has eaten for years or to foods that he has never eaten before.

Any system/organ of the body can be affected by an allergic reaction to foods

Skin	Gastrointestinal	Respiratory	Cardiovascular	Neurologic
Hives	Vomiting	Wheezing	Low Blood Pressure	Tiredness
Itching	Tongue Swelling	Cough	Rapid Heart Beat	Feeling that Something is Very Wrong
Red Skin	Itchy Mouth	Shortness of Breath	Palpitations	Passing Out
Mottled Skin	Difficulty Swallowing	Rapid Breathing	Chest Pain	Disorientation
Blue/Pale Skin	Stomach Pain	Not Able to Breathe	Heart Attack
Eczema	Bloating	Pulmonary Bleeding
Dry Skin	Diarrhea	Itchy Nose
	Constipation	Rhinitis
	Blood in Stool	Throat Swelling
	Colics	Hoarseness

Many diseases have been associated with food allergy, in some diseases there is a clear association, in others,it is not that clear

Food Anaphylaxis. Immediate food allergy mediated by immunoglobulin E (IgE). The reaction occurs minutes after ingesting or being exposed to the specific food. Most of the symptoms appear within 30 minutes or less, but some may take up to two hours. Generally two or more systems/organs are affected. Skin may show hives and flushing, lungs could wheeze or cough, throat may swell up, blood pressure could drop. Food anaphylaxis is a very scary situation that could lead to death.
Oral Allergy Syndrome. Mouth and/or throat itchiness and tingling associated with the ingestion of certain foods (fruits in most of the cases).
Eczema. Also known as dry skin or atopic dermatitis. "The itch that rashes". Food allergy has been associated with eczema, more clearly in young children than in adults. All children with eczema would benefit from a complete evaluation to decide if foods are contributing to their eczema.
Urticaria and Angioedema. Skin condition characterized by hives or skin swelling. Foods, among many other things, can cause these conditions and food allergy should be evaluated.
Food Protein-Induced Enterocolitis (FPIEC). This is a relatively rare condition where the patients react with severe vomiting and bloody diarrhea 30-60 minutes after ingesting a specific protein, which in most cases is cow's milk protein. This disorder is not mediated by IgE, but it is thought to be mediated by T-cells.
Food Protein Proctitis. This disorder is similar to FPIEC but a lot milder. It happens mostly in young infants and presents as bloody stools.
Eosinophilic Disorders of the Gastrointestinal Tract. Eosinophils (a type of white blood cell) may be found in the esophagus, stomach, or lower gastrointestinal tract. Food allergy has been implicated in a good percentage of these disorders. Eosinophilic Esophagitis has been associated with food allergy in more than 50% of the cases. Patients' symptoms vary according what area of the gut is affected.
Asthma and Rhinitis. The association of asthma and rhinitis with food allergy has been made, but in most of the cases associated with other symptoms and signs, such as the ones seen in very severe generalized reactions (anaphylaxis). Certain foods can induce rhinitis and/or wheezing, but it is not common to find those symptoms alone.
Food-associated Exercise-induced Anaphylaxis or Wheezing. Certain patients may develop an acute allergy reaction or wheezing if they eat a specific food and exercise within 2 hours. It is a relatively rare condition and does not occur if those patients eat that specific food only and do not exercise, or if they exercise without previously eating that specific food.
Gastroesophageal Reflux. Cows milk allergy has been associated with reflux. A complete evaluation is recommended.
Gastrointestinal Symptoms. Vomiting, stomaches, colics, bloating, diarrhea, bloody stools, and constipation have been associated to food allergy. Most of the patients presenting with these symptoms will not have a real food allergy, but another type of an adverse food reaction. A physician needs to evaluate these patients and consider referral to an allergist for further evaluation.
Pulmonary Hemosiderosis. A very uncommon disorder. It is seen mainly in young infants. It has been associated with milk allergy. Patients present with chest infiltrates, anemia, and gastrointestinal blood loss.
Celiac Disease. This disease is characterized by an immune response to a food protein (gluten).
Dermatitis Herpetiformis. This condition presents as a very itchy rash, located mainly on the buttocks and extensor surfaces of limbs. It is associated with celiac disease in some cases.

As you can see, there are many disorders associated with food allergy. A complete evaluation by a physician specialized in those disorders should be conducted in order to decide if foods are really a problem and how those problems should be addressed.

There a several methods that can be used to evaluate patients for food allergy

Medical History. During the initial interview, the provider tries to identify what food or foods are associated to the reactions the patients are being evaluated for.
Diet Diary. The patients or parents keep a daily diary that contains what type of food was consumed and what reactions where seen at what time. This information helps the provider determine the type of food allergy with more precision than a medical history.
Food Elimination Trial. One food is eliminated from the diet after determining that it is the most likely food causing the symptoms. If there is a complete resolution of symptoms it is possible that that food was causing those symptoms.
Prick Skin Test. This type of test is performed by scratching the skin with a prick containing with the food that is being evaluated. The results are read in 15-20 minutes. This test helps to identify IgE reactions to foods. A reaction showing a wheal 3 milimeters bigger in diameter than the wheal produced by water is read as a positive reaction. Foods should not be injected into the skin (intradermal tests) on a routine basis because this can lead to very severe reactions (even death).
Patch Test. Food is placed on a small chamber and left on the skin for 48 hours. The chamber is then removed and the skin reaction is evaluated. This test helps to identify non-IgE reactions to foods.
Blood Test (RAST). IgE specific levels to foods. This type of test is looking for the specific antibody (IgE) against foods in blood. RAST stands for radioallergosorbent test. Currently there are cutoff values that help the physicians decide if it is recommended to perform a food challenge in people labeled as "food allergic".
Food Challenge. There are several types of food challenges, including open, single-blinded, double-blinded, and the gold standard, the double-blinded placebo-controlled food challenge (DBPCFC). The open challenge is routinely conducted in young infants where the suspected food is given in incremental quantities (starting from a drop and finishing with a full cup) in a matter of several hours. The DBPCFC requires that neither, the patient nor the provider know what food is being tested. These challenges are serious and should be ordered and supervised by a physician.
Food provocation under Endoscopy. During this test a small amount of food is placed inside the stomach and the local reaction is evaluated by looking at the area with a special camera and obtaining a very small piece of tissue.

There are other tests available that do not have enough scientific support to be performed : IgG or IgG₄ antibody levels, food antigen-antibody complexes, lymphocyte activation, and sublingual or intracutaneous provocation.

Your doctor will discuss the importance of each test and how it applies to you. Do no hesitate to ask if you have questions.

Labelling somebody as "food allergic" is not something that should be taken or done lightly. The repercutions could be major

Should that person eat that food again?
How long should that food be avoided?
What if it is a food that is contained in many things, such as milk, soy, wheat?
What is that person going to eat if there are too many foods that she or he is allergic to?
How can somebody be certain that he or she is allergic to a specific food?
Foods provide nutrition and if we limit them, nutrition could be compromised affecting growth and development.
There needs to be a plan in place in case a food allergic person is accidentally exposed to foods that he or she is severely allergic to.
Some medicines and vaccines contain traces of foods, should those be avoided too?
What will happen at school or at the family table when other children are eating foods that a child is allergic too?
What about traveling and food allergy?

The above are just a few concerns and thoughts that need to be considered before making a diagnosis of food allergy.

In order to make a diagnosis of food allergy, the medical provider utilizes a combination of methods currently available and approved to be used in the office. After a detailed evaluation, history and physical exam, and food allergy tests performed during the initial visit, the patient will know that she or he:

Is not allergic to that food and can eat it safely, OR
May not be allergic to that food, and a food challenge is the next step to take, OR
Is allergic to that food and that food should be avoided, OR
Was allergic to that food and a food challenge should be conducted to demonstrate that it is now safe to eat that food, OR
Has symptoms that are not allergic in nature, but are due to an adverse food reaction, OR
Should stop eating a specific food and record a food diary meanwhile, OR
Should have more testing before deciding what to do, OR
Needs to be evaluated by another physician because the history and physical exam indicate that there could be something else besides food allergy.

Due to the potential dangers that food allergy carry, it is very important that all patients have a very detailed visit with their provider and a specific plan is elaborated. The diagnosis of food allergy follows a road map that your provider will explain to you.

At the end of the visit with your provider you should feel that all your doubts were clarified, that you know how to reach your doctor in case of an emergency, and that you have resources, such as written information and websites, to help you further understand the conditions that you were seen for.

The management and treatment of food allergies can be divided in two sections: a. avoidance of exposure and b. treatment of reactions

Avoidance of Exposure

If somebody is allergic to a certain food, the best approach is to avoid ingesting that food. It sounds soooo easy, doesn't it? But that might not be the case! Avoiding a food that is rarely used by most people is a lot easier than avoiding common foods. For example, milk, egg, and soy (just to mention a few) are often used in many foods that in order to totally avoid them, one needs to read labels, know that they are not contaminating other foods, know what medicines might contain them, and more. Let's see some cases:

If a product says that it contains "casein", "whey", "lactalbumin", "caramel color", "hydrolysates", "ghee", "nougat", or "butter", it means that there is milk in it. And these are a few names for milk.
Some companies utilize the same machines to make different foods. If they prepare chocolates just after making peanut treats, it is possible that the chocolates may be contaminated with peanuts. A peanut allergic boy can have an allergic reaction to a chocolate in this case (because the chocolate contained traces of peanuts).
Some medicines contain food products. For example, the influenza vaccine ("the flu shot") has traces of eggs. Atrovent (an inhaler) has traces of peanut.
If somebody is cooking fish, a fish allergic person may have a reaction by smelling the fumes the cooking is producing.
If a child drinks milk and immediately kisses a milk allergic child, the kissed child may have a reaction.

As you can see, sometimes it is not easy to avoid certain foods. This is why food allergic people need to read a lot and know where hidden foods can be found.

Treatment of Reactions

There are several medicines available to treat allergic reactions. By far, the most effective and important one during an acute reaction is epinephrine , also known as adrenaline. This medicine is the best counter for allergic reactions. Other medicines that help reduce the severity of an allergic reaction include antihistamines (H1 and H2 blockers) and steroids. Oxygen, intravenous fluids, glucagon, albuterol, and other medicines are also frequently used.

The management of an acute allergic reaction or Anaphylaxis should be supervised by somebody trained in these reactions. It is quite common that providers not trained in anaphylaxis try to avoid the use of epinephrine, with serious consequences to the patient.

Patients that have severe allergic reactions to foods should carry with them epinephrine ("Epi-Pen") in case they are accidentally exposed to certain foods. Epinephrine should be used immediately while an ambulance is being called.

We have a link to a diagram showing the way food allergies are handled: Management Road Map

Food allergy prevention is a hot topic and lots of research and studies are being conducted

There are 3 very important factors that determine if one is to become allergic to foods: genetics, environment, and timing.

Genetics: It has been shown that allergies tend to run in families. A child born to allergic parents has an increased possibility of being allergic than a child born to healthy parents.

Environment: In order for someone to become allergic to a certain food, he/she needs to be exposed to that food (or a very similar protein). If that "meeting" never happens, allergy to that food will not develop. In other words, people become allergic to foods that are presented to them by the environment.

Timing: There are some critical periods of the human development when allergies are more prone to develop. It is thought that during infancy the immune system is skewed to mount allergic responses rather than other protective reactions. This skewing plus the immaturity of the gastrointestinal system during that age seem to promote the development of food allergy in certain individuals.

Prevention of Food Allergy

The American Academy of Pediatrics (AAP) has recommendations on how to prevent or delay food allergy symptoms. Those recommendations indicate that breast milk is an excellent source of nutrition and breastfeeding should be carried out for a year or longer. Breastfeeding mothers whose infants have food allergies may benefit from eliminating cow's milk, egg, fish, peanuts and tree nuts from their diet. The use of hypoallergenic formulas should be considered in infants presenting with symptoms.

The AAP also recommends that solid food should not be introduced until 6 months of age, dairy until 1 year of age, eggs until 2, and peanuts, nuts, and fish until 3 years of age. If you are interested in reading more about those recommendations, click on the links provided above.

Of note: It seems that restricting diets of pregnant women to try to avoid development of allergies in their future child is of little benefit. The use of probiotics ("healthy bacteria") needs to be studied further before being recommended to patients.

If there is a question that you would like us to answer, please, send it to us

It might take a few days or a week in order to post the answer to your question here, but it will help you and other patients with the same concern. Be careful: do not send personal information! Please, review the questions below, maybe a similar question similar to yours was already answered.

Additional information and other resources can be found at:

Please, be careful when looking at information on this site and also on the other sites for which we provide links. Discuss your findings with your doctor and have him approve your plans before you implement any changes

Need an appointment?

If you would like to have your child seen in the Pediatric Pulmonary/Allergy Clinic call us at (573)-882-6921. That is the number for the front desk of the multi-specialty clinics. The clinic is located on the first floor of the University Physician's Medical Building, on 1101 Hospital Drive, corner of Hitt Street (see map below).

As there are several providers seeing patients on different days of the week, be sure to let the clerks know what problem your child has or what doctor you would like to see.

If after looking at this web site, you still have questions you can reach one of the nurses at (573) 882-1786.

General Instructions for first-time visitors/patients:

As you know, your child has an appointment scheduled in the Pediatric Pulmonary/Allergy Clinic. We would like to explain what you can expect that day. The first visit may take up to 3 hours or more. We recommend that you do not schedule any other appointments that day. When you arrive at the University Physician's Medical Building, go directly to the Pediatric Specialty Clinic. There, a clerk will enter information in the computer concerning your address, phone numbers, insurance, etc, or update what is already there. When the clerk asks you for the name of our referring physician, please give them the name of your child's local physician. It will be used to send a report of our findings and recommendations. Please help them make sure all information listed is current. We may need to contact you in the future.

During the initial visit a detailed history of your child's problem will be taken. He/she will be examined and various procedures may be done. We will explain any procedure before it is begun and encourage you and your child to ask questions at any point. Some of the tests that may be requested include pulmonary function testing, allergy skin testing, drug tests, food challenges, high flow nebulizer treatment, and an oxygen saturation check. The physician may also request chest and/or sinus X-rays or certain blood tests if these are necessary.

If allergy testing has not been done in the last 2 years or if you think your child needs to be tested, please do not give him/her any short-acting antihistamines (given every 4-6 hours, such as Dimetapp Elixir or Benadryl Elixir) for at least 72 hours. Do not give any long-acting antihistamine (given every 12-24 hours such as Rynatan, Claritin, Zyrtec, Allegra, or hydroxyzine) for at least a week. Hismanal must not be given for at least 3 weeks. Also, some "stomach" medicines can interfere with testing, such as Zantac (Ranitidine) and Pepcid (Famotidine), and these need to be held for at least 24 hours. If you are unsure about your child's medications, you can ask your pharmacist or doctor, or call our nurse.

To allow us to evaluate your child's pulmonary status, please do not give any short-acting bronchodilators (such as Albuterol, Proventil, Ventolin, or Maxair) for 3 hours prior to the appointment time (if possible).

To help make this visit as productive and comfortable as possible, please bring the following:

All original chest or sinus X-ray films.
Copies of records from your local physician and any other specialists seen for this problem.
Copies of records from hospitalizations.
All medications your child is currently taking and any that have been tried for the current problem in the past.
A few favorite toys, books, or homework to help occupy necessary waiting.
If children are small, a snack such as crackers or dry cereal is helpful.
Your insurance information, medicaid card, or any other means you are planning to use for payment.

Before you leave, the provider will explain your child's diagnosis and the treatment plan. Also, the nurse will spend time explaining the treatment plan in more detail, giving you printed information as well as phone numbers and directions on how to contact us in the future for questions and/or problems.

Need directions?

About Us

The Food Allergy Clinic belongs to the Division of Pulmonary/Allergy of the Department of Child Health of the University of Missouri at Columbia.

We are a team integrated by several providers (physicians and nurse practitioners), nurses, respiratory therapists, social workers, nutritionists, clerks, and other auxiliary staff.

The great variety on the background and experience of each member of the team is a plus when it comes to patient care. The patients benefit from this variety which strongly supports the education of other health care members and the patient him/herself.

If you have any questions you can reach us at (573) 882-6978 or send us an e-mail.

Please note that the e-mail system is for general questions and it should not be used for patient care.

This link is for clinic staff only.

Forms and extra information.

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