MANAGEMENT OF FOOD ALLERGIES

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MANAGEMENT OF FOOD ALLERGIESFederal Bureau of PrisonsClinical GuidanceNOVEMBER 2017Clinical guidance documents are made available to the public for informational purposes only. TheFederal Bureau of Prisons (BOP) does not warrant this guidance for any other purpose, and assumes noresponsibility for any injury or damage resulting from the reliance thereof. Proper medical practicenecessitates that all cases are evaluated on an individual basis and that treatment decisions are patientspecific. Consult the BOP Health Management Resources Web page to determine the date of the mostrecent update to this document: http://www.bop.gov/resources/health care mngmt.jsp

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 2017WHAT’S NEW IN THIS DOCUMENT?Several updates have been made since the September 2012 version of this document, including thefollowing: The order of the Appendices has been changed somewhat. Please see the Table of Contents on thenext page. Pharmacologic management of anaphylactic food allergies should focus on the use of epinephrine,usually via an auto-injector that is on the inmate’s person at all times. Epinephrine auto-injectors areprocessed as a pill-line item. Inmates will present the device at pill line at least once daily to verifythat the seal is intact and has not been manipulated. The current Appendix 3, Emergency Treatment of Anaphylaxis (Outpatient), replaces the formerAppendix 5, Pharmacological Treatment of Anaphylaxis. The table has been updated to include morespecific information about repeating epinephrine injections, as well as revisions to the informationabout additional and optional therapies. Consultation with a Central Office Dietitian is emphasized when developing Special Diets for foodallergies, including patient education and counseling services. For inmates at Medical ReferralCenters (MRCs), a consultation should be placed to an MRC staff registered dietitian. For all otherinstitutions, a dietitian consultation should be placed in BEMR and a Central Office registereddietitian should be contacted. The algorithms for patients with and without suspected food-induced anaphylaxis (see Appendix 4and Appendix 5) have been modified to highlight the need for referral to a Central Office RegisteredDietitian for: Individuals with multiple food allergies Patients in special housing units Patients on a Certified Diet Institutions that offer the High Rise or Controlled Movement versions of the National Menu Fruit exchange options have been substantially expanded since 2012. This version of the guidancerefers simply to “fruit,” rather than enumerating all the options. Internal and external hyperlinks have been updated. The format of the document has been updated for improved readability.i

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 2017TABLE OF CONTENTS1. PURPOSE . 12. FOOD ALLERGY OVERVIEW . 1Food Allergy vs. Food Intolerance . 1Prevalence of Food Allergies . 1IgE-Mediated and Non-IgE-Mediated Food Allergic Reactions . 1Diagnosis . 2Treatment . 33. FOOD ALLERGY ASSESSMENT . 3Medical History. 3Physical Exam. 3Assessment . 44. EVALUATION AND MANAGEMENT OF POTENTIAL ANAPHYLACTIC FOOD ALLERGIES . 45. EVALUATION AND MANAGEMENT OF POTENTIAL NON-ANAPHYLACTIC FOOD ALLERGIES . 46. DIET ORDERS . 5Medical Diet Orders/Self-Selection . 5Special Diet Orders . 57. DIETITIAN REFERRAL . 58. NUTRITION EDUCATION . 69. SATELLITE FEEDING . 610. WORK AND HOUSING DETAIL . 6GENERAL DEFINITIONS. 7REFERENCES . 8APPENDIX 1: DEFINITIONS OF SPECIFIC FOOD-I NDUCED ALLERGIC CONDITIONS . 9APPENDIX 2: DIAGNOSTIC CRITERIA FOR ANAPHYLAXIS . 11APPENDIX 3: EMERGENCY T REATMENT OF ANAPHYLAXIS (OUTPATIENT). 13APPENDIX 4: ALGORITHM FOR PATIENTS WITH SUSPECTED F OOD-INDUCED ANAPHYLAXIS . 14APPENDIX 5: ALGORITHM FOR PATIENTS WITHOUT HISTORY OF SUSPECTED FOOD-INDUCED ANAPHYLAXIS . 15APPENDIX 6: BOP FOOD ALLERGY QUESTIONNAIRE . 16APPENDIX 7: I NMATE HANDOUTS . 18Inmate Factsheet: An Overview of Food Allergies . 19Inmate Factsheet: Lactose Intolerance . 20Inmate Factsheet: Food Avoidance and Self-Selection from the BOP National Menu . 21ii

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 20171. PURPOSEThe Federal Bureau of Prisons (BOP) Clinical Guidance for the Management of Food Allergiesprovide recommendations for the diagnosis and management of federal inmates with suspectedfood allergies.2. FOOD ALLERGY OVERVIEWFOOD ALLERGY VS. FOOD INTOLERANCEFood allergy has no basic universally accepted definition. The National Institutes of Health(NIH) defines food allergy as “an adverse immune response that occurs reproducibly onexposure to a given food and is distinct from other adverse responses to food, such as foodintolerance, pharmacologic reactions, and toxin-mediated reactions.” However, in publishedarticles on food allergy, definitions frequently vary, thereby confounding the recommendationson diagnosing and managing patients with food allergies. Nevertheless, the distinction between afood allergy with an allergic response and food intolerance, such as the inability to digest thesugar lactose, is clinically relevant. See the General Definitions section in this guidance, as well as Appendix 1, Definitions of SpecificFood-Induced Allergic Conditions.PREVALENCE OF FOOD ALLERGIESThe prevalence of food allergies is poorly defined, and estimates range from 0.2–3.5% in thegeneral population. Estimates of peanut allergy prevalence range from 0.3–0.9%.Although childhood food allergies tend to wane with aging, a subset of these patients will havefood allergies that persist into adulthood. Furthermore, some adults develop allergies de novofrom sensitization to food allergens encountered after childhood.IGE-MEDIATED AND NON-IGE-MEDIATED FOOD ALLERGIC REACTIONSThe distinction between IgE-mediated reactions and non-IgE-mediated reactions to foodallergens is clinically important. IgE-mediated food allergic reactions are rapid in onset, typically beginning within minutes totwo hours from the time of ingestion. Presentations include circulatory collapse, dyspnea,wheezing, stridor, angioedema, oropharyngeal symptoms, and urticarial rash. The mostcommon foods associated with anaphylaxis are peanuts, tree nuts, and crustacean shellfish;however, milk and eggs can also induce IgE-mediated allergic responses. Non-IgE-mediated reactions are much more subacute or chronic and are usually isolated tothe gastrointestinal tract and/or skin.1

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 2017DIAGNOSIS There are no well-accepted criteria for diagnosing food allergies. However, certain diagnostics testsare NOT recommended for evaluating food allergies: intradermal allergen testing, total serum IgEquantification, and atopy patch testing.Skin prick tests and serum food-specific IgE assays are potentially valuable diagnostic tests forfood allergies; however, neither one is superior to the other, and both are considerednonconfirmatory of a specific food allergy—thus limiting their diagnostic efficacy. Skin prick testing for a given food allergy is not very specific diagnostically, as patients witha positive test still have a 40% chance of being able to eat the food in question withoutdifficulty. Food-specific IgE assays (commonly known as RAST tests) are sensitive tests diagnostically,but also are not very specific. If negative, the specific food allergy is unlikely. If positive, thepatient still may not have a true food allergy. These tests are most useful for confirming thediagnosis of a suspected specific food allergy. In the BOP, the primary role for RAST testing is to confirm allergy to milk, wheat, or bakedegg in inmates with a history of anaphylaxis. IgE assays to a panel of potential antigens areusually not helpful or indicated—except possibly when ruling out claims of multiple foodallergens—and should only be ordered in consultation with the Central Office RegisteredDietitian.The gold standard for diagnosing a food allergy is a placebo-controlled oral food challenge.However, this testing requires specialized personnel, time, expense, and the risk of anaphylaxis,thereby limiting the use of this diagnostic test in the community, let alone within the correctionalsetting. Therefore, in evaluating BOP inmates for food allergies, the focus should be onidentifying inmates at risk for anaphylaxis: providing them epinephrine, if indicated, and pursuingdiagnostic testing on a very limited basis, primarily for those with questionable IgE-mediatedfood allergies. The vast majority of inmates with food allergies, those with non-IgE-mediatedallergies, should be provided education on targeted food selection.Within the BOP, a diagnosis of a food allergy shouldpatient’s health problem unless:NOTbe confirmed and documented as a1. The food allergy was previously diagnosed by an outside medical provider and documented inthe patient’s medical records.2. The patient was diagnosed while in BOP custody, using standards indicated in this guidance,including: A thorough assessment has been conducted with the use of Appendix 6, BOP Food AllergyQuestionnaire, and the patient has been identified as having a history of reproducible foodallergy-related symptoms upon exposure to an identified allergen. The specific food allergen has been positively confirmed with RAST testing, as outlined inAppendix 4, Algorithm for Patients with Suspected Food-Induced Anaphylaxis, or Appendix 5,Algorithm for Patients Without History of Suspected Food-Induced Anaphylaxis.2

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 2017TREATMENTElimination diets are the mainstay of therapy for patients with food allergies, although theeffectiveness of this strategy is poorly studied. Immunotherapy for food allergies is unproven andnot recommended. Pharmacologic management of anaphylactic food allergies should focus onthe use of epinephrine, usually via an auto-injector that is on the inmate’s person at all times.3. FOOD ALLERGY ASSESSMENTMEDICAL HISTORYThe medical history should focus on: Any past history of food allergy evaluations. Anaphylactic episodes (including emergency room visits, hospitalizations, and prescriptionsfor hand-carried epinephrine). History of poor outcomes from anaphylaxis therapy related to the use of beta-blocker orACE inhibitor therapy. History of asthma (particularly poorly controlled) or coronary artery disease. The timing and descriptions of symptoms relative to ingestion of specific foods, e.g.,wheezing, voice change related to laryngeal edema, urticaria, or rashes. The association of allergic symptoms with exercise or other complementary factors such asthe use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or alcohol. A history of asthma, dysphagia, or eosinophilic esophagitis. A personal or family history of atopic dermatitis. Clinicians should familiarize themselves with Appendix 1, which outlines the wide range of specificfood-induced allergic conditions that may be diagnostically relevant. Key questions for evaluating foodallergies are outlined in Appendix 6, BOP Food Allergy Questionnaire.PHYSICAL EXAMThe physical exam should include: Vital signs Pulse oximetry Weight measurement Auscultation of the lungs, HEENT, CV Thorough examination of the skin for signs of atopic dermatitisOther examinations should be conducted to evaluate for other co-morbidities that are indicatedby the patient’s medical history.3

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 2017ASSESSMENTAn assessment should be made as to whether or not anaphylactic food allergy is a concern, basedon the inmate’s medical history of IgE-mediated allergic episodes and the specific offendingfood allergens. See the diagnostic criteria and related information outlined in Appendix 2, Diagnostic Criteria forAnaphylaxis.4. EVALUATION AND MANAGEMENT OF POTENTIAL ANAPHYLACTIC FOOD ALLERGIESInmates with suspected anaphylactic food allergies should be evaluated and managed inaccordance with the stepwise approach outlined in Appendix 4, Algorithm for Patients with SuspectedFood-Induced Anaphylaxis.Inmates who have bona fide medical history of anaphylactic food allergies (e.g., history ofhospitalization or EpiPen prescriptions) should be: Prescribed an epinephrine auto-injector to be carried by the inmate at all times. Epinephrineauto-injectors are processed as a pill-line item. Inmates will present the device at pill line atleast once daily to verify that the seal is intact and has not been manipulated. (See the BOPNational Formulary, Part 1.) Given a copy of the Inmate Factsheet: An Overview of Food Allergies, which offers informationon potential anaphylactic symptoms and the use of self-administered epinephrine. Provided appropriate information on food selections, such as that in the Inmate Fact Sheet:Food Avoidance and Self-Selection from the BOP National Menu. Given information on reading food labels, as available at the Food Allergy Research &Education (FARE) website. General information on “How to Read Food -labels. Printable handout, “Tips for Avoiding Your pdf. Inmate Factsheets are available in Appendix 7. Guidance for health care providers on the preventionand treatment of anaphylaxis is outlined in Appendix 3, Emergency Treatment of Anaphylaxis(Outpatient).5. EVALUATION & MANAGEMENT OF POTENTIAL NON-ANAPHYLACTIC FOOD ALLERGIESInmates with suspected non-IgE-mediated food allergies should be evaluated and managed inaccordance with the stepwise approach shown in Appendix 5, Algorithm for Patients Without Historyof Suspected Food-Induced Anaphylaxis. The algorithm outlines how patients with suspected foodallergies must be managed for various allergens: fruit, baked egg, wheat, milk, anotherindividual food, or multiple foods.Clinicians should also be aware of the potential association of certain diseases and syndromeswith non-IgE-mediated food allergies, as outlined in Appendix 1, Definitions of Specific FoodInduced Allergic Conditions. Inmates diagnosed with lactose intolerance should be given a copy ofthe Inmate Fact Sheet: Lactose Intolerance, available in Appendix 7.4

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 20176. DIET ORDERSMEDICAL DIET ORDERS/SELF-SELECTIONDiet orders for food allergies are to be offered only when medically necessary—and not for foodintolerance or preference. In all cases when a diet order is being considered, the first optionshould be the inmate’s simple avoidance of the item, with guidance provided by the Inmate FactSheet: Food Avoidance and Self-Selection from the BOP National Menu, available in Appendix 7.For all individual food allergies except fruit, baked egg, wheat, or milk, the inmate may simplyavoid the item or self-select the no-flesh option or heart-healthy alternative option. In accordancewith the BOP Guidelines for Medical Diets, medical diets that will be provided through selfselection may be ordered by any mid-level practitioner (MLP), clinical director (CD), staffphysician, staff psychiatrist, or staff dentist.SPECIAL DIET ORDERSA Special Diet should not be considered for allergic avoidance, unless: The food allergy is reported for fruit.The individual has a confirmed diagnosis of allergy to baked egg, wheat, or milk, or aconfirmed diagnosis of multiple-food allergies.In accordance with the Program Statement PS6031.01, Patient Care: Special Diets will be prescribed only by the CD or by a staff physician, staff psychiatrist, orstaff dentist.MLPs at Medical Referral Centers (MRCs) may prescribe a Special Diet, but it must becountersigned by the primary physician.All Medical and Special Diets related to food allergies must be: Documented in the patient’s medical record.Furnished in writing via e-mail to the Food Service Administrator (FSA).Rewritten annually or more often if indicated.7. DIETITIAN REFERRALFor individuals at Medical Referral Centers (MRCs), if a Special Diet for a food allergy isordered, a consultation should be placed to an MRC staff registered dietitian. For all otherinstitutions, if a Special Diet for a food allergy is ordered, a dietitian consultation shouldbe placed in BEMR and a Central Office registered dietitian should be contacted.The registered dietitian will work with the institution FSA to ensure that appropriate precautionsare taken with regard to elimination of causative foods, preparation of meals, and (if needed)appropriate dietary substitutions to the National Menu to maintain nutritional adequacy.5

Federal Bureau of PrisonsClinical GuidanceManagement of Food AllergiesNovember 20178. NUTRITION EDUCATIONIf indi

a positive test still have a 40% chance of being able to eat the food in question without difficulty. Food-specific IgE assays (commonly known as RAST tests) are sensitive tests diagnostically, but also are not very specific. If negative, the specific food allergy is unlikely. If positive, the patient still may not have a true food allergy.

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