Non‐IgE‐mediated gastrointestinal food allergies in children

Non‐IgE‐mediated gastrointestinal food allergic disorders (non‐IgE‐GI‐FA) including food protein‐induced enterocolitis syndrome (FPIES), food protein‐induced enteropathy (FPE), and food protein‐induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under‐diagnosed. Non‐IgE‐GI‐FA have a favorable prognosis, with majority resolving by age 3–5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.     

Cytokine profile of food‐allergic post‐liver transplant children is identified by high levels of IL‐5 and low IL‐10 secretion from patients' peripheral blood mononuclear cells

Severe allergic reaction to food following liver transplantation is a well‐known phenomenon. However, the mechanisms underlying this phenomenon are not yet elucidated. This study aimed to reveal the nature of the immune response in post‐transplanted allergic patients and compare them to non‐allergic transplanted as well as allergic and non‐allergic control subjects, with focus on cytokine milieu. Post‐liver transplant patients with and without allergic reactions as well as food‐allergic but otherwise healthy and healthy non‐allergic control patients were recruited. We reviewed patient records and routine laboratory tests and assayed subjects' PBMCs, studying cytokine secretion profile in response to different stimuli. Post‐transplant patients with food allergy showed a unique cytokine profile in response to various stimuli, with extremely elevated IL‐5, low IL‐10 secretion, and somewhat higher IFN‐γ. T regulatory cell number was not significantly different among the groups of patients and controls. Immune response of food‐allergic post‐liver transplant patients is identified by a unique cytokine profile when compared to allergic but otherwise healthy individuals.     

Is there an association between microbial exposure and food allergy? A systematic review

The environmental factors driving the recent increase in the prevalence of food allergy (FA) are unclear. Since associations have been demonstrated between microbial exposure and the likelihood of eczema and respiratory allergies, we reviewed the evidence for FA. Medline was systematically searched from inception to the end of July 2012 for studies investigating links between FA and environmental exposures, likely to influence microbial exposure, such as Caesarean delivery, family size, day‐care attendance, childhood infections, immunizations and antibiotic use. We selected studies reporting food challenge data, reported doctor‐diagnosed (RDD) FA and food sensitization. Methodological differences and study heterogeneity precluded meta‐analysis. A total of 46 studies were identified, of which 28 (60.9%) were prospective and 13 (28.3%) used food challenges to diagnose FA. Caesarean delivery was investigated in 13 studies, of which three infant cohorts demonstrated an increase in challenge‐proven FA (one cohort) and food sensitization (two cohorts), and one cross‐sectional study reported increased RDDFA. Four studies investigated the effect of having siblings, with one infant cohort demonstrating less challenge‐proven FA and a cross‐sectional study showing a decrease in RDDFA. Attending childcare before 6 months was associated with less challenge‐proven FA in one cohort. A cross‐sectional survey identified an inverse relationship between hepatitis A serology and peanut sensitization. One of eleven trials investigating probiotics demonstrated a quicker acquisition of milk tolerance amongst allergic infants. Factors influencing microbial exposure may be partly responsible for rising FA burden, but further prospective studies using double‐blind placebo controlled food challenges as an outcome are required.     

Allergen immunotherapy for IgE‐mediated food allergy: There is a measure in everything to a proper proportion of therapy

IgE‐mediated food allergy (FA) is a potentially life‐threatening condition with a negative impact on quality of life and an increasing prevalence in westernized countries in the recent two decades. A strict avoidance of the triggering food(s) represents the current standard approach. However, an elimination diet may be difficult and frustrating, in particular for common foods, (eg, milk, egg, and peanut). Food allergy immunotherapy (FA‐AIT) may provide an active treatment that enables to increase the amount of food that the patient can intake without reaction during treatment (ie, desensitization), and reduces the risk of potential life‐threatening allergic reaction in the event of accidental ingestion. However, several gaps need still to be filled. A memorable Latin orator stated: “Est modus in rebus” (Horace, Sermones I, 1, 106‐07). This sentence remembers that there is a measure in everything to a proper proportion of therapy. The common sense of measure should find application in each stage of treatment. A personalized approaching should consider the specific willing and features of each patient. Efforts are devoted to improve the efficacy, the safety but also the quality of life of patients suffering from FA. In the near future, it will be important to clarify immunologic pathways of FA‐AIT, and to identify reliable biomarkers in order to recognize the most suitable candidates to FA‐AIT and algorithms for treatments tailored on well‐characterized subpopulations of patients.     

Food Allergy in childhood: phenotypes,prevention and treatment

The prevalence of food allergy in childhood increased in the last decades, especially in Westernized countries where this phenomenon has been indicated as a second wave of the allergic epidemic. In parallel, scientific interest also increased with the effort to explain the reasons of this sudden rise and to identify potential protective and risk factors. A great attention has been focused on early exposures to allergenic foods, as well as on other nutritional factors or supplements that may influence the immune system in a positive direction. Both interventions on maternal diet before birth or during breastfeeding and then directly on infant nutrition have been investigated. Furthermore, the natural history of food allergy also seems to be changing over time; IgE‐mediated cow's milk allergy and egg allergy seem to be more frequently a persistent rather than a transient disease in childhood, as described in the last years. Food avoidance and the emergency drugs in case of an adverse event, such as epinephrine self‐injector, are currently the first‐line treatment in patients with food allergies, with a resulting impairment in the quality of life and social behaviour. During the last decade, oral immunotherapy emerged as an optional treatment with remarkable results, offering a novel perspective in the treatment for and management of food allergy.     

Food allergy after liver transplantation in children: a prospective study

Food allergy has been increasingly reported in children who had orthotopic liver transplantation (OLT). We aimed to conduct a prospective study to investigate the prevalence of sensitizations and food allergy in pediatric OLT recipients. We also aimed to identify potential risk factors. The study group consisted of 28 children (14 male, 14 female, mean age 4.96 ± 0.76 yrs) who had OLT. Total eosinophil count (TEC), total IgE, and specific IgEs were studied before and 3, 6, 12 months after OLT. Six patients (21%) developed multiple food allergies. Mean age of six patients at OLT who developed food allergy was younger compared to the non‐food allergy group (10.2 months vs. 68.9 months, p < 0.05). Food allergy has been developed within 1 yr in 5, and in 20 months in one patient after OLT. All six patients had cow’s milk and egg allergy after OLT. Five children developed wheat, one children developed lentil and another one developed peach allergy in addition to cow’s milk and egg allergy. Out of six food‐allergic patients after OLT, four children developed Epstein–Barr virus (EBV) infection prior to food allergy. Before OLT, TECs and total IgE levels were not differed among food allergic and non‐food allergic patients (p > 0.05). Mean of TECs were significantly higher in food allergic group compared to non‐food allergic group at each time point after OLT (p < 0.05). Though statistically insignificant, mean of total IgE levels were also higher in the food allergic group (p > 0.05). These findings suggest that food allergy should be considered after OLT in patients who are younger than 1 yr of age, who developed hypereosinophilia, high total IgE levels or EBV viremia.     

Parents' estimate of food allergy prevalence and management in Italian school‐aged children

Background: Despite the increasing prevalence of food allergy, few studies have assessed the prevalence of perceived food‐induced symptoms among school‐aged children. There is also a paucity of data on how children with food reactions are managed. We investigated the frequency and characteristics of perceived food reactions in school‐aged children. Methods: Children aged 5–14 years were included in this cross‐sectional study. A standardized self‐administered questionnaire on food reactions was handed out to 900 parents. Results: We achieved a response rate of 69%. The lifetime prevalence of parental perceived allergic reactions to food was 10.5%; the point prevalence was 1.6%. Medical care included a call to a general practitioner in 54% of cases, self‐management in 37%, an emergency call in 6%, and hospitalization in 3%. Antihistamines were administered in 45% of food reactions, topical steroids in 24%, oral or parenteral steroids in 16%, and epinephrine in 1.5%. In children who reported food reactions, skin prick tests for foods were performed in 54% of cases; the oral food challenge test was performed in 7.5%. Conclusion: Parent perception of food allergic disorders is common in school‐aged children. Few children have undergone diagnostic tests to ascertain clinical food hypersensitivity. This is warranted to avoid unnecessarily restricted diets. Efforts should be made to train primary care physicians to manage food‐allergic children.     

Human milk polyunsaturated long‐chain fatty acids and secretory immunoglobulin A antibodies and early childhood allergy

The possible protective effect of breast milk against atopic manifestations in infancy, i.e. atopic eczema and food allergy, has been controversial for the last decades. Besides the methodological problems, differences in the composition of human milk could explain these controversies. The aim of this study was to investigate the composition of polyunsaturated fatty acids (PUFA) and secretory immunoglobulin A (S‐IgA) levels to food proteins (ovalbumin and β‐lactoglobulin) and an inhalant allergen (cat) in milk from mothers of allergic and non‐allergic children. Blood samples were obtained at birth and at 3 months from 120 children. Skin prick tests were performed at 6, 12 and 18 months, and the development of atopic diseases was assessed in the children. Breast milk samples were collected from their mothers at birth and monthly during the lactation period. Milk PUFA composition was measured by gas chromatography, and enzyme‐linked immunosorbent assay (ELISA) was used to measure total S‐IgA, anti‐cat S‐IgA, anti‐ovalbumin S‐IgA, and anti‐β‐lactoglobulin S‐IgA. Allergic disease developed in 44/120 children (22/63 children of allergic mothers and 22/57 children of non‐allergic mothers). Lower levels of eicosapentaenoic acid, C20:5 n‐3 (EPA), docosapentaenoic acid C22:5n‐3 (DPA), and docosatetraenoic acid C22:4 n‐6 (DHA) (p < 0.05 for all) were found in mature milk from mothers of allergic as compared to milk from mothers of non‐allergic children. The total n‐6 : total n‐3 and the arachidonic acid, C20:4 n‐6 (AA) : EPA ratios were significantly lower in transitional and mature milk from mothers of allergic children, as compared to milk from mothers of non‐allergic children. The PUFA levels in serum of allergic and non‐allergic children were largely similar, except for higher levels of C22:4 n‐6 and C22:5 n‐6 (p < 0.05 for both) and a higher AA : EPA ratio in serum phospholipids in the former group (p < 0.05). Changes in the levels of milk PUFA were reflected in changes in PUFA serum phospholipids, particularly for the n‐6 PUFA. The AA : EPA ratio in maternal milk was related, however, to the AA : EPA only in serum from non‐allergic children, while this was not the case in allergic children. The levels of total S‐IgA, anti‐cat S‐IgA, anti‐ovalbumin S‐IgA, and anti‐β‐lactoglobulin S‐IgA in milk from mothers of allergic, as compared to non‐allergic, children were similar through the first 3 months of lactation. Low levels of n‐3 PUFA in human milk, and particularly a high AA : EPA ratio in maternal milk and serum phospholipids in the infants, were related to the development of symptoms of allergic disease at 18 months of age. The milk PUFA composition influenced the composition of PUFA in serum phospholipids of the children. We also showed that the lower levels of colostral anti‐ovalbumin S‐IgA and lower total S‐IgA in mature milk from atopic mothers did not influence the development of allergic disease in the children up to 18 months of age. The findings indicate that low α‐linolenic acid, C18:3 n‐3 (LNA) and n‐3 long‐chain polyunsaturated fatty acids (LCP) 20–22 carbon chains, but not the levels of S‐IgA antibodies to allergens, are related to the development of atopy in children.     

Fish intake during pregnancy or infancy and allergic outcomes in children: A systematic review and meta‐analysis

It has been suggested that n‐3 long‐chain polyunsaturated fatty acids (n‐3 LC‐PUFAs) have anti‐inflammatory properties and may reduce the risk of allergic disease. Fish is a great source of n‐3 LC‐PUFAs. However, the effect of fish on allergic disease remains controversial. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) and prospective cohort studies regarding the effect of fish intake during pregnancy or infancy on allergic outcomes in children. The outcomes of interest were atopy, eczema, allergic rhinitis, wheeze, asthma, and food allergy. One RCT and 17 publications from 13 prospective cohort studies were included for maternal fish intake during pregnancy, and eight publications from five prospective cohort studies for fish intake in infancy. Pooled analysis suggested that maternal fish intake during pregnancy was not associated with lower risk of any allergic outcome, both in RCT and observational studies. Consumption of fish during the first year of life reduced the risk of eczema (RR 0.61; 95% CI 0.47, 0.80; p = 0.0003; I² = 68%) and allergic rhinitis (RR 0.54; 95% CI 0.36, 0.81; p = 0.003; I² = 74%). Current evidence indicates that fish intake in infancy could reduce the risk of eczema and allergic rhinitis in children, whereas maternal fish intake during pregnancy does not affect any atopic outcome. The intake of fish per se in infancy, not specially n‐3 LC‐PUFAs, may have an allergy protective effect. High‐quality and adequately powered RCTs are warranted to confirm this.     

OPINION: Primary prevention of allergy – Will it soon become a reality?

It is generally accepted that allergic diseases are not curable and not preventable, but mainly controllable using pharmacotherapy (i.e. symptomatic medication). Recent research, however, demonstrated that a number of specific interventions can lead to (partial) primary prevention of allergy, especially of atopic dermatitis (AD) and food allergy (FA). Three types of primary prevention strategies have been successfully studied: early administration of bacterial products (most studies are on probiotics), early moisturizing in infants at risk for AD and early exposure to allergenic foods (peanut and egg). Results of these studies indicate that the stage might have been set. Surely, much more research needs to be carried out before advice can be given in clinical practice. This opinion article discusses the three types of beneficial interventions and gives ideas for future research, which might show the way for better strategies in primary prevention of allergic diseases.     

Prevalence of food allergy among preschool children in northern Thailand

Background: The epidemiology and clinical spectrum of food allergies (FA) confirmed by oral food challenge tests (OFC) in the Southeast Asian countries are limited. The aim of the present study was to examine the prevalence and characteristics of FA among preschool children in northern Thailand. Methods: Five hundred and forty‐six children aged 3–7 years living in Chiang Mai, Thailand participated in this study. A cross‐sectional parent questionnaire survey was conducted. Families with children reporting FA were invited to undergo further investigations with skin prick testing, serum specific IgE, and OFC. Results: A total of 452 out of 546 questionnaires (82.8%) were returned. Forty‐two children (9.3%) were reported to have FA. The five leading allergic foods reported were shrimp, cow's milk, fish, chicken eggs, and ant eggs. The most commonly reported symptom was a skin rash (78.0%), followed by abdominal pain and vomiting (31.1%). Anaphylaxis was found in two children (3.4%), from ant eggs allergy. Eighteen children underwent OFC; five of them were positive to shrimp, fish, and crab. Either skin prick test or serum‐specific IgE was positive in these children. Factors associated with parent‐reported FA included personal and family history of atopic dermatitis. Conclusions: The prevalence of IgE‐mediated FA confirmed on OFC was ≥1.11% (95% confidence interval: 0.41–2.98%). The most common causative food was shrimp. Ant eggs were a unique food allergen causing severe reactions in preschool children in northern Thailand.     

Treating IgE‐mediated diseases via targeting IgE‐expressing B cells using an anti‐CεmX antibody

Targeting the IgE pathway is a clinically validated strategy for treating IgE‐mediated diseases. Omalizumab, an anti‐IgE antibody, which binds to free IgE and prevents the binding of IgE to FcεRI on mast cells and basophils has been approved for severe persistent allergic asthma and chronic spontaneous (idiopathic) urticaria. The therapeutic efficacy of anti‐IgE has also been reported in allergic rhinitis, allergic bronchopulmonary aspergillosis, latex allergy, atopic dermatitis, allergic urticaria, anaphylaxis, and others. Anti‐CεmX, which binds to membrane‐bound IgE (mIgE) on IgE‐switched B cells, lyses mIgE‐expressing B lymphoblasts and prevents the allergen‐induced generation of IgE‐producing plasma cells, offers an alternative mechanism of intervening with the IgE inflammatory pathway. Because anti‐CεmX does not bind to free IgE, it can modulate the IgE pathway regardless of the serum IgE levels in treated patients. These unique pharmacologic mechanisms potentially enable anti‐CεmX to provide different clinical utilities from anti‐IgE and serve as a therapeutic and a prophylactic in some IgE‐mediated diseases, which are not adequately treated with current medicine.     

Epicutaneous sensitization to food allergens in atopic dermatitis: What do we know?

Atopic dermatitis (AD) is a chronic inflammatory skin disease mainly affecting children, which has no definitive curative therapy apart from natural outgrowing. AD is persistent in 30%-40% of children. Epithelial barrier dysfunction in AD is a significant risk factor for the development of epicutaneous food sensitization, food allergy, and other allergic disorders. There is evidence that prophylactic emollient applications from birth may be useful for primary prevention of AD, but biomarkers are needed to guide cost-effective targeted therapy for high-risk individuals. In established early-onset AD, secondary preventive strategies are needed to attenuate progression to other allergic disorders such as food allergy, asthma, and allergic rhinitis (the atopic march). This review aims to describe the mechanisms underpinning the development of epicutaneous sensitization to food allergens and progression to clinical food allergy; summarize current evidence for interventions to halt the progression from AD to food sensitization and clinical food allergy; and highlight unmet needs and directions for future research.     

Are avoidance diets still warranted in children with atopic dermatitis?

Nearly 40% of children with moderate-to-severe atopic dermatitis (AD) have IgE-mediated food allergy (FA). This clinical observation has been extensively documented by experimental data linking skin inflammation in AD to FA, as well as by food challenges reproducing symptoms and avoidance diets improving AD. Although food avoidance may improve AD, avoidance diets do not cure AD, may even have detrimental effects such as progression to immediate-type allergy including anaphylactic reactions, and may significantly reduce the quality of life of the patient and the family. AD care should focus upon optimal medical management, rather than dietary elimination. Food allergy testing is primarily indicated when immediate-type allergic reactions are a concern. In recalcitrant AD, if food is being considered a possible chronic trigger, a limited panel of foods may be tested. An avoidance diet is only indicated in patients clearly identified as food allergic by an appropriate diagnostic food challenge, and after adequately informing the family of the limited benefits, and possible harms of an elimination diet.     

Why do few food‐allergic adolescents treat anaphylaxis with adrenaline? – reviewing a pressing issue

Food allergic adolescents are at higher risk of fatal anaphylaxis than other children. Both allergen avoidance and maintaining access to adrenaline auto‐injectors (AAI) are key goals in effective food allergy management, for which written guidance is often supplied. However, adolescents are rarely sufficiently prepared to use adrenaline during anaphylaxis. It is likely that further didactic education would bring limited improvement in management in this population. Focused discussion of each adolescent's perspectives and current management practice may allow more effective behavioural strategies to be adopted. Key areas for appraisal include subjects' experiences after previous allergen exposure with reference to worst response, recognising specific symptoms requiring AAI administration, and appropriate priority being given to timeliness of administering adrenaline. Behavioural strategies should be discussed to increase AAI accessibility. Rigor of allergen avoidance should not be compromised by false reassurance of proximity to emergency medication or medical services. Food allergic adolescents are motivated by the psychological impact of their condition, which often makes them feel different to their peers and may result in bullying. Methods of appropriately empowering adolescents may be considered, such as involvement of close friends and lay organisations to support appropriate management. Open discussion is crucial in engaging with adolescents' reasoning for adopting their chosen management strategies. Further research is warranted to identify cognitive patterns associated with high‐risk behaviour, and to design appropriate interventions for the augmentation of adolescent self‐management skills.     

Peanut seed storage proteins are responsible for clinical reactivity in Spanish peanut‐allergic children

Background: Seed storage proteins (SSP; Ara h 1, Ara h 2, Ara h 3) have been shown to be major peanut allergens, although recently, peanut lipid transfer protein has been reported to be an important allergen in the Mediterranean area. We sought to investigate the sensitization pattern to peanut SSP and vegetable pan‐allergens in a group of peanut‐allergic children compared with a peanut‐tolerant group. Methods: One hundred and twenty‐three children who presented with food allergy were included in the study. Tolerance to peanut ingestion was assessed. Specific IgE was determined by ImmunoCAP, and microarray ISAC was performed. Sensitization frequencies and levels of specific IgE were compared between groups. Results: Fifty‐five of 123 children presented symptoms upon contact or ingestion. Frequency of sensitization to Ara h 1, Ara h 2, and Ara h 3 was 60.0%, 72.7%, and 43.6%, respectively, in the group of allergic children vs. 7.4%, 1.5%, and 7.4% in the group of tolerant children. Levels of specific IgE against Ara h 1, Ara h 2, and Ara h 3 were significantly higher in the allergic group (p < 0.001). The frequency of sensitization and the levels of specific IgE against Cor a 8 (36.4% vs. 16.2%) were significantly higher in the allergic children, whereas no significant differences were found for Pru p 3. No differences were seen for other pan‐allergens. Patients sensitized to SSP, regardless of sensitization to nsLTP, were allergic rather than tolerant. Conclusion: In our population, peanut‐allergic children were mainly sensitive to SSP. A few patients were also sensitive to some nsLTPs. No differences were shown in other pan‐allergens.     

Immunotherapy – risk/benefit in food allergy

Food allergy is a growing health concern in the westernized world with approx. 6% of children suffering from it. A lack of approved treatment has led to strict avoidance of the culprit food proteins being the only standard of care. Nowadays in‐depth research is conducted to evaluate the possible use of allergen‐specific immunotherapy (SIT) as an active therapeutic option for food allergy. Various routes of administration for the immunotherapy are investigated, including subcutaneous, oral, sublingual, and epicutaneous, and some appear to be successful in inducing a temporary tolerant state. Most research has been conducted with oral immunotherapy due to its efficacious and relatively safe profile. Increasing interest is dedicated to safer and more convenient approaches, such as sublingual and epicutaneous SIT; however, doubts exist about their possible capacity to induce temporary tolerant state and permanent oral tolerance. The high frequency of allergic adverse reactions of the various approaches and the inability to achieve permanent oral tolerance have highlighted the need of refinements in the strategies. A promising strategy for preventing IgE cross‐linking and thus enhancing safety of SIT, while still activating T cells, is the use of tolerogenic peptides. The implementation of such an immunotherapy approach has the potential of not only increasing the chance of achieving a permanent state of tolerance, but also improving the safety and tolerability of the therapy. Immunotherapy for food allergy is still not ready for the clinic, but current and upcoming studies are dedicated to collect enough evidence for the possible implementation of allergen‐SIT as a standard treatment for food allergy.     

Monitoring of IgE-mediated food allergy in childhood

Background: The prevalence of IgE-mediated food allergy (FA) in childhood varies from 6% to 8% in the first year of life compared to 1% to 2% in adults. In contrast to adults, FA in childhood, often part of the “allergic march”, resolves in more than 85% of children, especially those with hypersensitivity to cow's milk and egg. Aim: This paper explains the rationale for continuing care for childhood FA and describes how children should be monitored for resolution/persistence of FA. Methods: A clinical, multidisciplinary approach and management algorithm based on relevant, peer-reviewed original research articles and reviews using the keywords anaphylaxis, atopic eczema, children, milk allergy, double-blind placebo-controlled food challenge, egg allergy, epinephrine, failure to thrive, food allergy, food challenge, food hypersensitivity, immunoglobulin E, nutrition, natural history, paediatrics, peanut allergy, prevalence, psychosocial factors, quality of life, radioallergosorbent test, and tolerance from years 1966 to 2003 in MEDLINE. Additional studies were identified from article reference lists. Results: A combination of outcome measures, a multidisciplinary approach involving a dietitian and allergy nurse specialist, and a management algorithm are useful tools in clinical management.

Conclusions: Prospective studies of non-selected children, optimally from birth cohorts, are needed to evaluate the effects of such management programmes regarding FA in childhood.     

Fish allergy in childhood

Fish and its derived products play an important role in human nutrition, but they may also be a potent food allergen. Fish can be an ingested, contact, and inhalant allergen. Gad c I, a Parvalbumin, the major allergen in codfish, is considered as fish and amphibian pan‐allergen. Prevalence of fish allergy appears to depend on the amount of fish eaten in the local diet. In Europe, the highest consumption occurs in Scandinavian countries, Spain and Portugal. In Spain, fish is the third most frequent allergen in children under 2 yr of age after egg and cow’s milk. An adverse reaction to fish may be of non‐allergic origin, due to food contamination or newly formed toxic products, but the most frequent type of adverse reactions to fish are immunologic‐mediated reactions (allergic reactions). Such allergic reactions may be both IgE‐mediated and non‐IgE‐mediated. Most cases are IgE‐mediated, due to ingestion or contact with fish or as a result of inhalation of cooking vapors. Some children develop non‐IgE‐mediated type allergies such as food protein induced enterocolitis syndrome. The clinical symptoms related to IgE‐mediated fish allergy are most frequently acute urticaria and angioedema as well as mild oral symptoms, worsening of atopic dermatitis, respiratory symptoms such as rhinitis or asthma, and gastrointestinal symptoms such as nausea and vomiting. Anaphylaxis may also occur. Among all the species studied, those from the Tunidae and Xiphiidae families appear to be the least allergenic.     

Rice protein‐induced enterocolitis syndrome with transient specific IgE to boiled rice but not to retort‐processed rice

Described herein is the case of an 8‐month‐old girl with atypical food protein‐induced enterocolitis syndrome due to rice. She presented with vomiting and poor general activity 2 h after ingestion of boiled rice. Oral food challenge test using high‐pressure retort‐processed rice was negative, but re‐exposure to boiled rice elicited gastrointestinal symptoms. On western blot analysis the patient's serum was found to contain IgE bound to crude protein extracts from rice seed or boiled rice, but not from retort‐processed rice. The major protein bands were not detected in the electrophoresed gel of retort‐processed rice extracts, suggesting decomposition by high‐temperature and high‐pressure processing. Oral food challenge for diagnosing rice allergy should be performed with boiled rice to avoid a false negative. Additionally, some patients with rice allergy might be able to ingest retort‐processed rice as a substitute for boiled rice.