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REFERATE GENERALE

4
ALERGIA ALIMENTAR I ASTMUL BRONIC
Dr. Claudia Ierima1, Prof. Dr. Alexandru Dimitriu1, Dr. Augustin Ierima2
1
Universitatea de Medicin i Farmacie Gr.T. Popa, Iai
2
Facultatea de Medicin i Farmacie, Universitatea Dunrea de Jos, Galai

REZUMAT
Pe plan mondial, alergia alimentar reprezint o problem de sntate public de mare actualitate, cu o
inciden n continu cretere. Asocierea acesteia cu exacerbrile astmului bronic sunt descrise n tot mai
multe studii multicentrice internaionale. n acest context, prezentul articol evideniaz rolul alimentelor n
simptomatologia tractului respirator i circumstanele n care alergia alimentar trebuie luat n considerare
la pacienii cu astm bronic i/sau rinit alergic.

Cuvinte cheie: alergie alimentar, astm bronic, rinit alergic

Astmul bronic este o boal cu o prevalen o reacie mediat imunologic fr legtur cu un


crescut, fiind o cauz major de morbiditate n efect fiziologic al alimentului sau aditivului (precum
populaia pediatric, n special cea din mediul urban edemul laringeal, tusea i wheezingul, ca urmare a
(1). Este bine cunoscut faptul c, la pacienii atopici, ingestiei unor alune la pacienii alergici). Intolerana
sensibilizarea la alergenii alimentari apare mult alimentar reprezint un rspuns fiziologic anormal
mai precoce comparativ cu sensibilizarea la pneu- la alimente, care nu este mediat imunologic.
moalergeni, factori triggeri ai astmului bronic (2). Adevrata prevalen a simptomelor respiratorii
Pe plan mondial, alergia alimentar reprezint o induse de alergia alimentar a fost i este dificil de
problem de sntate public de mare actualitate, estimat. Numeroase studii recente care au implicat
cu o inciden n continu cretere, mai ales la i teste de provocare alimentare au estimat incidena
copiii din marile orae (1,3,4). Asocierea acesteia cazurilor de astm bronic exacerbat ca urmare a
cu exacerbrile astmului bronic sunt descrise n tot ingestiei unor alimente ca fiind cuprins ntre 2-8%
mai multe studii multicentrice internaionale, att la copii, ct i la aduli (7). De asemenea, nu-
cunoscut fiind faptul c bronhospasmul poate fi un meroi pacieni astmatici au declarat c aditivii ali-
simptom al alergiei alimentare (2). Incidena mentari le agraveaz simptomatologia, studiile
crizelor de astm bronic induse de unele alimente a evideniind o prevalen a acestora mai mic de 5%
fost estimat de pn la 8,5% (5). (8).
Prezentul articol dorete s evidenieze rolul Diferitele locaii geografice, dieta, etnia pot pre-
alimentelor n simptomatologia tractului respirator zenta contribuii variabile n patogenia alergiei ali-
i circumstanele n care alergia alimentar trebuie mentare. Oule, laptele, alunele, soia, petele, fruc-
luat n considerare n special la pacienii cu astm tele de mare, dar i unii aditivi precum sulfii i
bronic, rinit alergic i anafilaxie respiratorie. aspartamul sunt cteva alimente frecvent implicate
Premergtor oricrei discuii referitoare la alergia n reacii respiratorii i confirmate de numeroase
alimentar, se impune nelegerea clasificrii reac- studii ce au efectuat teste de provocare de tip orb
iilor adverse la alimente. Acestea reprezint un (9-11).
rspuns clinic anormal, ca urmare a ingestiei unor Dei adesea simptomele sunt cauzate post in-
alimente sau aditivi alimentari (6). Aceste reacii gestie a alimentelor, au fost ntlnite cazuri n care
sunt mprie n dou mari categorii: alergia ali- doar inhalarea alergenului alimentar (de exemplu
mentar i intolerana alimentar. Prima reprezint fina) a putut cauza fenomene precum tuse,

Adresa de coresponden:
Dr. Ierima Claudia, Universitatea de Medicin i Farmacie Gr. T. Popa, Str. Universitii Nr. 16, Iai
e-mail: ierimaclaudia@yahoo.com

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REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011 335

wheezing i dispnee la buctari. Mai mult, n unele anatomice, precum polipi nazali, deviaie de sept,
studii s-a remarcat apariia simptomelor respiratorii dischinezie ciliar, corpi strini. Alergia alimentar
nu n urma expunerii ocupaionale, ci chiar i ca ca i trigger al unor simptome respiratorii a fost
urmare a intrrii pacienilor ntr-un restaurant sau foarte puin cercetat comparativ cu infeciile trac-
buctrie n care se prepara pete sau ou (12). n tului respirator, rinita alergic i sinuzita.
acest sens, un studiu a remarcat c 9 din 21 de pa- Cu toate acestea, este cunoscut faptul c, la pa-
cieni alergici la pete au prezentat wheezing i cienii sensibilizai, alergenii alimentari contribuie
rinit ca urmare a expunerii acestora la aburul i la creterea reactivitii cilor respiratorii i, n
mirosul de pete, 3 dintre acetia prezentnd i unele cazuri, la exacerbri ale astmului, fapt ce a
simptome cutanate (13). Deloc de neglijat sunt i fost demonstrat ntr-un studiu de tip orb, n care
unele cazuri n care pacienii alergici la alune copii astmatici cu alergii alimentare au fost evaluai
prezint reacii adverse respiratorii ca urmare a pentru modificri ale reactivitii cilor respiratorii
expunerii i inhalrii prafului de alune n mijloacele nainte i dup provocri alimentare (20,21). n
de transport n comun, mai ales n cursele aeriene urma testelor de provocare la alimente, creterile
care servesc snacksuri cu alune (14). semnificative ale reactivitii cilor aeriene s-au
Factorii de risc ai alergiei alimentare au fost asociat i cu simptome respiratorii, nefiind observate
identificai ca fiind reprezentai de vrsta copilriei scderi ale FEV1. Deci, reaciile alergice induse de
(1-19 ani), sexul masculin i rasa neagr. n copilrie alimente pot crete reactivitatea cilor respiratorii
cele mai rspndite alergii alimentare sunt la lapte la pacienii cu astm moderat pn la sever, fr
i la ou. Exist o tendin global descresctoare a modificri ale funciei pulmonare i fr a induce
alergiei alimentare odat cu naintarea n vrst, simptome de astm acut.
observndu-se c alergia la ou i lapte se remite n Alte studii au evideniat c unele simptome na-
timp, ns cea la arahide i crustacee persist (9,15). zale pot fi atribuite ingestiei de alimente. De
Relaia dintre gravitatea alergiei alimentare i astm exemplu, unii pacieni asociaz ingestia laptelui de
poate fi una de cauzalitate, observndu-se episoade vac i a altor produse lactate cu creterea secreiilor
de astm bronic sever induse de alergia alimentar nazale. n urma unui studiu orb placebo-controlat
la unii pacieni (16,17). provocat la alimente, pe un lot semnificativ de pa-
Alergia alimentar poate fi prima manifestare la cieni, simptomele nazale au reprezentat 70% dintre
sugarii cu dermatit atopic care progreseaz spre manifestrile respiratorii (22). De asemenea, s-a
rinit alergic i astm bronic. Cele mai comune observat c rinita este de obicei asociat cu alte
manifestri clinice ale alergiei alimentare implic manifestri clinice (precum, simptome gastroin-
pielea i tractul gastro-intestinal (18). Uneori, testinale i cutanate) n timpul reaciilor alergice la
simptome ale tractului respirator superior i inferior alimente i rar apare izolat (23,24). Produsele ali-
pot rezulta ca urmare a unei reacii alergice la mentare care induc rinita au fost observate mai
alimente. Aceste simptome sunt mai rare i adesea frecvent la sugari i copii mici, dect la aduli.
nsoite de simptome cutanate sau gastrointestinale. Reaciile anafilactice datorate unor alimente i
Reaciile respiratorii izolate sunt foarte rare. O care implic tractul respirator includ de obicei prurit
mare varietate de simptome respiratorii au fost la nivelul orofaringelui, angioedem (edem larin-
atribuite alergiei alimentare, incluznd congestia gian), stridor, tuse, dispnee, wheezing i disfonie.
nazal, rinoreea, strnutul, pruritul nazal i la ntr-un raport de ase cazuri fatale i apte cazuri
nivelul gtului, tusea i wheezingul. Aproximativ aproape fatale de reacii anafilactice dup ingestie
6% dintre copiii astmatici prezint simptome ale alimentar, astmul bronic i simptomele respiratorii
tractului respirator inferior induse de alimente (19). au fcut parte din tabloul clinic al tuturor pacienilor
Dermatita de contact apare la numeroi comerciani (1). Alimentele responsabile pentru aceste reacii
sau angajai care vin n contact direct cu pete crud, grave au fost arahidele, nucile, oule i laptele de
crustacee, ou, carne. n evaluarea pacienilor cu vac. Deci, prezena astmului bronic i a alergiei
aceste simptome clinice, diagnosticul diferenial alimentare, n special la alergenii menionai
trebuie s includ, suplimentar bolilor alergice (ri- anterior pot fi considerai drept factori de risc
nita alergic, astm i alergia alimentar), boli in- semnificativi pentru acutizarea astmului, cu pre-
fecioase (infecii virale ale tractului respirator cdere n formele severe (20,21).
superior, otit medie recurent, sinuzit), rinita Unii aditivi alimentari sunt, de asemenea, incri-
non-alergic (ca urmare a schimbrilor climatice, a minai i nc cercetai referitor la impactul lor
mirosurilor puternice sau a fumului de igar), asupra pacientului astmatic. n ciuda percepiei pu-
rinita medicamentoas, fibroza chistic i anomalii blice, exist dovezi conflictuale, referitoare la unii
336 REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011

pacieni astmatici care sunt mai susceptibili de a Rezultatele examenului fizic sunt folosite pentru
prezenta efecte adverse la glutamat monosodium evaluarea global a strii nutriionale, evidenierea
comparativ cu populaia general (25). Dei pa- creterii parametrilor i prezena semnelor de boal
cienii au acuzat simptome respiratorii superioare alergice, mai ales dermatit atopic. Dermatita
sau inferioare nespecifice, reaciile adverse la atopic sever sau moderat sau corticosteroid
glutamat monosodium, n funcie de doz, au inclus dependent poate anticipa un risc ridicat de astm
cefalee, tensiune muscular, amoreal, slbiciune indus alimentar. n plus, aceast examinare ajut la
general, precum i nroirea feei n cteva ore de excluderea altor afeciuni care pot imita alergiile
la ingerare. Alimentele care conin sulfii (fructe alimentare.
uscate i vinuri) s-au dovedit, de asemenea, a Testele cutanate (neptur i puncie) sunt uti-
provoca bronhospasm i atacuri de astm moderat lizate pentru a evidenia alergiile alimentare IgE
pn la sever la pacienii astmatici sensibili (6). mediate (26). Se pot efectua nc din primele luni
Aspartamul, agent de ndulcire utilizat n buturi, dup natere, iar utilizate mpreun cu criterii stan-
nitriii i nitraii utilizai drept conservani, tartra- dard de interpretare, aceste teste pot oferi informaii
zina, hidroxianisolul butilat i hidroxitoluenul bu- clinice ntr-o perioad scurt (15-20 de minute).
tilat (conservani n cereale) sunt substane asociate Valoarea predictiv negativ este mai mare de 95%.
n numeroase studii cu urticaria i angioedemul. Valoarea predictiv pozitiv este n general sub 50%,
Aditivii alimentari naturali utilizai frecvent sunt limitnd interpretarea clinic a testelor cutanate
reprezentai de annatto, carmin, ofran i erythritol, pozitive (6). Acest lucru subliniaz necesitatea de a
care pot prezenta la pacienii sensibili reacii ne- confirma istoricul clinic i testele cutanate pozitive
dorite, inclusiv manifestri respiratorii. cu o provocare alimentar dac istoricul nu este
Diagnosticul se realizeaz n baza unui istoric convingtor pentru anafilaxie. n cazul extractelor
medical completat cu teste de laborator adecvate i alimentare comerciale (de exemplu, fructe i le-
provocri alimentare care pot furniza informaii gume), degradarea proteinelor alimentare poate
utile pacienilor cu simptome respiratorii care pot fi crete rata testelor cutanate fals negative. Prin ur-
provocate de alergia alimentar (25). Un diagnostic mare, trebuie utilizate extractele proaspete care
bazat numai pe istoric sau doar pe un test cutanat sunt mai fiabile. Testarea cutanat intradermic cu
nu este suficient. n prezena unor teste cutanate alimente crete riscul de a induce o reacie sistemic
pozitive sau simptome respiratorii asociate cu pro- i mai puin specific n comparaie cu testul prin
duse alimentare specifice, se poate institui o diet neptur cutanat (6). Dei testarea cutanat de
de eliminare pentru 7-14 zile. n cazul n care rutin la alimente la pacienii astmatici nu este o
simptomele persist, nseamn c nu produsele practic, considerm c ar trebui realizat n special
alimentare sunt problema, cu excepia unor cazuri la pacienii cu astm bronic moderat i sever.
de dermatit atopic sau astm cronic. Simptomele Evaluarea alergiei alimentare n laborator poate
recurente dup o diet regulat ar trebui evaluate cu include msurarea IgE alimentare specifice n ser
un test de provocare alimentar bine intit. (de exemplu, RAST), cu sensibilitate i specificitate
Obinerea unui istoric exact este un element similare cu testele cutanate (25).
cheie n diagnosticul alergiei alimentare. Antece- Cnd exist suspiciunea clinic a unei reacii a
dentele medicale trebuie s fie cuprinztoare, deta- tractului respirator indus de alimente, iar testarea
liate, obinute de la pacienii suspectai de alergie pentru anticorpi IgE specifici pentru produsele ali-
alimentar ce induce simptome respiratorii. Natura mentare este pozitiv, se impune o diet pentru
exact a simptomelor, relaia dintre calendarul de eliminarea alimentelor incriminate pentru a vedea
ingerare al alimentelor i debutul simptomelor, dac simptomele clinice se remit. Dieta trebuie s
reproductibilitatea reaciilor, precum i detaliile fie bine echilibrat, pentru a oferi substituenii co-
dietetice trebuie s fie bine documentate. Un istoric respunztori pentru produsele alimentare care sunt
familial de alergie sau astm poate fi util. Atunci eliminate din diet i pentru a evita anticipat defi-
cnd exist un istoric de exacerbare inexplicabil cienele nutriionale, cum ar fi deficitul de calciu
de astm, ar trebui s se obin detalii despre ingestia (27). Cnd se instituie o diet, mai ales la sugari i
alimentelor. Istoricul unei reacii severe anafilactice copii, se monitorizeaz ndeaproape toi parametrii.
dup ingerarea unui produs alimentar poate fi Punerea n aplicare a unei diete de eliminare poate
suficient pentru a indica o relaie de cauzalitate. n prea simpl, ns ndeprtarea complet a unei
cele din urm, documentarea tratamentului specific alimentaii alergice necesit atenie la detalii. De
primit i rspunsul su, dac este cazul, sunt, de exemplu, n cazul unei diete fr lapte, pacienii
asemenea, utile. trebuie s fie educai s evite nu numai toate
REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011 337

produsele lactate, dar, de asemenea, s citeasc eti- deniaz faptul c simptomele induse alimentar
chetele cu ingredientele produselor alimentare pen- sunt IgE mediate, au o frecven mai mic, sunt
tru cuvintele cheie care pot indica prezena de prezente de obicei la pacienii tineri, n special la
proteine din lapte de vac (cazein, zer, lactalbu- cei cu un istoric de dermatit atopic. n plus,
min, lactoglobulin). alergia alimentar poate fi cu siguran un trigger la
Provocarea alimentar de tip orb, placebo-con- unii pacieni astmatici. Acest lucru trebuie luat n
trolat, este cea mai bun metod pentru a diagnos- considerare dac un pacient prezint wheezing (sau
tica i confirma alergia alimentar i alte reacii simptome anafilactice) dup ingerarea unui anumit
negative alimentare (12,26). Aceste provocri trebuie aliment, dac are dermatit atopic sau un istoric al
efectuate ntr-o clinic sau spital cu personal calificat acestei boli, dac prezint un istoric de alergii
i echipamente pentru tratarea anafilaxiei sistemice. alimentare sau teste cutanate pozitive la unele ali-
Un plan de urgen ar trebui s fie scris pentru a mente.
ajuta pacienii s gestioneze simptomele clinice Evaluarea alergiei alimentare se efectueaz la
cauzate de ingestia accidental a unui alergen rele- pacienii cu simptome cronice, n special la copiii
vant de produs alimentar. Pentru copii, planul tre- cu un istoric de dermatit atopic. Un diagnostic
buie s se adreseze personalului din coal, iar an- definitiv al alergiei alimentare ar trebui s se bazeze
tihistaminele i adrenalina trebuie s fie la ndemn pe un test de provocare oral de tip orb, placebo-
pentru a trata reacii alergice dup ingerarea acci- controlat.
dental. n anumite circumstane, cum ar fi un istoric
convingtor de anafilaxie ca urmare a ingerrii sau
CONCLUZII inhalrii unui produs alimentar sau aditiv alimentar,
un diagnostic prezumptiv bazat pe criterii mai
Studiile efectuate asupra rolului patogenic al stricte poate fi suficient.
alergiei alimentare n simptomele respiratorii evi-

Food allergy and asthma


Claudia Ierima, MD1, Alexandru Dimitriu, MD, PhD1; Augustin Ierima, MD2
1
Faculty of Medicine, Gr.T Popa University of Medicine and Pharmacy, Iasi
2
Faculty of Medicine and Pharmacy, Clinical Department,
Dunarea de Jos University, Galati

ABSTRACT
Worldwide, food allergy is a large and growing public health problem. Exacerbations associations with asthma
are described in many recent international multicenter studies. Therefore, this article seeks to highlight the
role of food in respiratory symptoms and the circumstances in which the food allergy should be considered
especially in patients with asthma and/or allergic rhinitis.

Key words: food allergy, asthma, allergic rhinitis

Asthma is a disease of high prevalence being a center studies, being known that bronchospasm
major cause of morbidity in the pediatric popula- may be a symptom of food allergy (2). The inci-
tion especially in urban areas (1). It is well known dence of asthma attacks induced by some foods
that at atopic patients, sensitization to food aller- was estimated to 8.5% (5). This article seeks to
gens occurs much earlier than awareness to pneu- highlight the role of food in respiratory symptoms,
moallergens, factors of asthma triggers (2). World- the circumstances in which the food allergy should
wide, food allergy is a matter of great public health, be considered especially in patients with asthma,
with a growing incidence, especially in children in allergic rhinitis and respiratory anaphylaxis.
large cities (1,3,4). Exacerbations associations with Precursor to any discussion of food allergy, it is
asthma are described in more international multi- necessary to understand the classification of ad-
338 REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011

verse reactions to food. These are an abnormal clini- and allergic rhinitis progressing to asthma. The most
cal response following the ingestion of food or food common clinical manifestations of food allergy in-
additives (6). These reactions are divided into two volve the skin and gastrointestinal tract (18). Some-
broad categories: food allergy and food intolerance. times symptoms of upper and lower respiratory tract
The first is an immunologically mediated response can result from an allergic reaction to food. These
unrelated to the physiological effects of food or ad- symptoms are rare and often accompanied by skin or
ditives (such as laryngeal edema, cough and wheez- gastrointestinal symptoms. Isolated respiratory reac-
ing due to ingestion of peanut allergic patients). Food tions are very rare. A variety of respiratory symp-
intolerance is an abnormal physiological response to toms were attributed to food allergies including na-
food, which is not immunologically mediated. sal congestion, runny nose, sneezing, itching nose
The true prevalence of food allergy-induced re- and throat, coughing and wheezing. Approximately
spiratory symptoms was and is difficult to estimate. 6% of asthmatic children have lower respiratory
Numerous recent studies that have also involved tract symptoms induced by food (19). Contact der-
food challenge tests have estimated incidence of matitis occurs at many retailers or employees who
asthma exacerbated by ingestion of food as being come in direct contact with raw fish, shellfish, eggs,
between 2-8% in children and adults (7). Also, meat. In evaluating patients with clinical symptoms
many patients with asthma reported that food addi- differential diagnosis must include additional aller-
tives aggravate their symptoms, their prevalence gic diseases (allergic rhinitis, asthma and food aller-
studies showing less than 5% (8). gy), infectious diseases (viral upper respiratory tract
infections, recurrent otitis media, sinusitis), non-
Different geographical locations, diet, ethnicity
allergic rhinitis (due to climate change, strong odors
may be variable contributions in the pathogenesis of
or cigarette smoke), rhinitis medicamentosa, cystic
food allergy. Eggs, milk, peanuts, soy, fish, seafood,
fibrosis and anatomic abnormalities such as nasal
and some additives such as sulfur and aspartame are
polyps, deviated septum, ciliary dyskinesia, foreign
some foods commonly implicated in respiratory re-
bodies. Food allergy as a trigger of some respirato-
actions and confirmed by numerous studies that were
ry symptoms has been very little studied compared
performed blinded challenge tests (9-11). with respiratory tract infections, allergic rhinitis
Although symptoms are often caused by post in- and sinusitis.
gestion of food, they were not uncommon to in- However, it is known that at sensitized patients,
haled allergen food (eg. flour) and could cause phe- food allergens contribute to increased airway reac-
nomena such as coughing, wheezing and dyspnea tivity and in some cases of asthma exacerbations,
at cooks. Moreover, some studies have noted no re- which was demonstrated in a blinded study in
spiratory symptoms after occupational exposure, which asthmatic children with food allergies were
but following the entry of patients in a restaurant or evaluated for changes in airway reactivity before
a kitchen where they cooked fish or eggs (12). A and after food challenges (20,21). Following the
study noted that 9 of 21 patients allergic to fish ex- food challenge test, significant increases in airway
perienced wheezing and rhinitis due to their expo- reactivity were associated with respiratory symp-
sure to steam and the smell of fish, 3 of them also toms, generally without decreases of FEV1. So
showing skin symptoms (13). Not neglected are food-induced allergic reactions may increase air-
some cases in which patients allergic to peanuts have way reactivity in patients with moderate to severe
respiratory effects following exposure and inhala- asthma without changes in lung function and with-
tion of peanut dust on public transport, and especial- out inducing acute asthma symptoms.
ly in air flights serving snacks with nuts (14). Other studies have shown that some nasal symp-
Food allergy risk factors were identified as rep- toms could be attributable to ingestion of food. For
resentatives of early childhood (1-19 years), male example, some patients associate the ingestion of
gender and black race. The most common child- cows milk and other dairy products, with increased
hood food allergies are milk and eggs. There is a nasal secretions. A blinded study placebo-controlled
global trend of decreasing food allergy with age, of food on a significant group of patients showed
observing that in the allergy to eggs and milk is re- that nasal symptoms were 70% of respiratory events
versed over time, but the peanut and shellfish re- (22). It was also noted that rhinitis is often associated
mains (9,15). The relationship between food allergy with other clinical manifestations (such as, gastroin-
and asthma severity could be causal, as seen in the testinal and skin symptoms) during allergic reactions
episodes of severe asthma induced by food allergy to foods and is rarely isolated (23,24). Foods that in-
in some patients (16,17). Food allergy can be the duce rhinitis were observed more frequently in in-
first manifestation in infants with atopic dermatitis fants and young children than in adults.
REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011 339

Anaphylaxis due to food and respiratory tract tween timing of food intake and onset of symptoms,
involving the oropharynx usually include pruritus, reactions and reproducibility of dietary details must
angioedema (laryngeal edema), stridor, cough, dys- be well documented. A family history of allergy or
pnea, wheezing and hoarseness. In a report of six asthma may be useful. When there is a history of
cases of fatal and seven near-fatal cases of anaphy- unexplained exacerbation of asthma, you should
laxis after ingestion food, asthma and respiratory obtain details of food intake. History of severe ana-
symptoms were part of the clinical picture of all phylactic reactions after ingestion of a food may be
patients (1). Foods responsible for these severe re- enough to indicate a causal relationship. Finally,
actions were peanuts, nuts, eggs and cows milk. documenting specific treatment received and its re-
So, the presence of asthma and food allergy in par- sponse, if any, are also useful.
ticular allergens mentioned above may be consid- Physical examination results are useful for over-
ered as significant risk factors for acute exacerba- all assessment of nutritional status, growth param-
tion of asthma, especially in severe forms (20,21). eters and the presence of allergic signs of disease,
Some food additives are also criminalized and especially atopic dermatitis. Moderate or severe
are further investigated on their impact on asthmat- atopic dermatitis or corticosteroid dependent may
ic patients. Despite public perception, there is con- predict a high risk of food-induced asthma. In addi-
flicting evidence relating to some patients with tion, this examination helps rule out other condi-
asthma that are more susceptible to adverse effects tions that may mimic food allergies.
from monosodium glutamate than the general pop- Skin tests (prick and puncture) are used to rein-
ulation (25). Although patients have accused upper force food allergies IgE mediated (26). They can be
or lower respiratory symptoms nonspecific adverse made during the first months after birth, and used
reactions to monosodium glutamate, dose-depen- together with standard criteria of interpretation;
dent and included headache, muscle tension, numb- these tests may provide clinical information in a
ness, general weakness and flushing in a few hours short period (15-20 minutes). Negative predictive
after ingestion. Sulfur-containing foods (dried fruits value is greater than 95%. Positive predictive value
and wine) also proved to cause bronchospasm and is generally below 50%, limiting the clinical inter-
asthma attacks of moderate to severe asthmatic pa- pretation of positive skin tests (6). This underlines
tients sensitive (6). Aspartame, the sweetening agent the need to confirm the clinical history and positive
used in beverages, nitrites and nitrates used as pre- skin tests with food challenge if history is not con-
servatives, tartrazine, butylated hydroxytoluene, bu- vincing for anaphylaxis. In the case of commercial
tylated hydroxyanisole and (preservatives in cereals) food extracts (eg. fruits and vegetables), food pro-
are substances associated with urticaria and angioe- tein degradation may increase the rate of false neg-
dema in numerous studies. Natural food additives ative skin tests. Therefore one must use fresh ex-
commonly used are represented by annatto, carmine tracts that are more reliable. Intradermal skin testing
and erythritol, which may be unwanted sensitive pa- with food increases the risk of systemic and pro-
tients, including respiratory symptoms. duce a less specific compared with skin prick test
Diagnosis is made based on a complete medical (6). Although routine skin testing to foods in asth-
history with appropriate laboratory tests and food matic patients is not practical, we believe that
challenges that can provide useful information to should be done especially in patients with moderate
patients with respiratory symptoms that may be and severe asthma. Evaluation of food allergy in
caused by food allergy (25). A diagnosis based the laboratory may include measuring serum IgE
solely on history or skin test is not enough. In the specific food (eg, RAST) sensitivity and specificity
presence of positive skin tests and respiratory similar to skin tests (25).
symptoms associated with specific foods, can es- When clinical suspicion of an adverse food-in-
tablish an elimination diet for 7-14 days. If symp- duced respiratory tract exists and testing for spe-
toms persist, it means that food is not the problem, cific IgE antibodies for food is positive, it is neces-
except in cases of atopic dermatitis or chronic asth- sary to eliminate foods incriminated to see if clinical
ma. Recurrent symptoms after a regular diet should symptoms resolve. The diet should be well bal-
be assessed with a food challenge test targeted. anced to provide suitable substitutes for foods that
Obtaining an accurate history is a key element are removed, and avoid nutritional deficiencies,
in diagnosing food allergy. Medical history should such as calcium deficiency (27). When establishing
be comprehensive, detailed, from patients with sus- a diet, especially in infants and children closely
pected food allergy inducing respiratory symptoms. monitor all the parameters. Implementation of the
The exact nature of symptoms, the relationship be- elimination diet may seem simple, but complete
340 REVISTA ROMN DE PEDIATRIE VOLUMUL LX, NR. 4, AN 2011

removal of allergic diets requires attention to detail. toms are IgE mediated, have a lower frequency and
For example, in a diet without milk, patients should are usually present in younger patients, especially
be educated not only to avoid all dairy products, those with a history of atopic dermatitis. In addi-
but also to read food labels ingredients for key- tion, food allergy can certainly be a trigger in some
words that may indicate the presence of cows milk patients with asthma. This should be considered if
protein (casein, whey, lactalbumin, lactoglobulin). a patient develops wheezing or anaphylactic symp-
Food challenge placebo-controlled is the best toms after ingesting certain food, if it has atopic
way to diagnose and confirm food allergy and other dermatitis or a history of the disease, if they have a
adverse food reactions (12, 26). These challenges history of food allergies or skin tests positive for
must be performed in a clinic or hospital with per- some food. Evaluation of food allergy is performed
sonnel and adequate equipment to treat systemic in patients with chronic symptoms, especially in
anaphylaxis. An emergency plan should be written children with a history of atopic dermatitis. A de-
to help patients manage clinical symptoms caused finitive diagnosis of food allergy should be based
by accidental ingestion of a relevant food allergen. on an oral challenge test blinded, placebo-con-
In case of children, the plan must be addressed to trolled. In certain circumstances, such as a convinc-
school personnel. Antihistamines and adrenaline ing history of anaphylaxis following ingestion or
should be on hand to treat allergic reactions after inhalation of a food or food additive, a presumptive
accidental ingestion. diagnosis based on stricter criteria may be suffi-
cient.
CONCLUSIONS
Studies on pathogenic role of food allergy in re-
spiratory symptoms shows that food-induced symp-

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