EAACI guidelines on the diagnosis of IgE-mediated food allergy

Alexandra F Santos^{1

2

3}, Carmen Riggioni⁴, Ioana Agache⁵, Cezmi A Akdis⁶, Mubeccel Akdis⁶, Alberto Alvarez-Perea^{7

8}, Montserrat Alvaro-Lozano^{9

10}, Barbara Ballmer-Weber^{11

12}, Simona Barni¹³, Kirsten Beyer¹⁴, Carsten Bindslev-Jensen¹⁵, Helen A Brough^{1

3}, Betul Buyuktiryaki¹⁶, Derek Chu¹⁷, Stefano Del Giacco¹⁸, Audrey Dunn-Galvin^{19

20}, Bernadette Eberlein²¹, Motohiro Ebisawa²², Philippe Eigenmann²³, Thomas Eiwegger^{24

25

26

27}, Mary Feeney¹, Montserrat Fernandez-Rivas^{28

29}, Helen R Fisher¹, David M Fleischer³⁰, Mattia Giovannini^{13

31}, Claudia Gray^{32

33}, Karin Hoffmann-Sommergruber³⁴, Susanne Halken³⁵, Jonathan O'B Hourihane³⁶, Christina J Jones³⁷, Marek Jutel³⁸, Edward Knol³⁹, George N Konstantinou⁴⁰, Gideon Lack^{1

2

3}, Susanne Lau¹⁴, Andreina Marques Mejias^{1

3}, Mary Jane Marchisotto⁴¹, Rosan Meyer^{42

43

44}, Charlotte G Mortz¹⁵, Beatriz Moya^{45

46}, Antonella Muraro⁴⁷, Caroline Nilsson^{48

49}, Lucila Camargo Lopes de Oliveira⁵⁰, Liam O'Mahony⁵¹, Nikolaos G Papadopoulos^{52

53}, Kirsten Perrett^{54

55

56}, Rachel L Peters^{54

55

56}, Marcia Podesta⁵⁷, Lars K Poulsen⁵⁸, Graham Roberts^{59

60

61}, Hugh A Sampson⁶², Jürgen Schwarze⁶³, Peter Smith^{64

65}, Elizabeth Huiwen Tham^{66

67

68}, Eva Untersmayr³⁴, Ronald Van Ree⁶⁹, Carina Venter⁷⁰, Brian P Vickery⁷¹, Berber Vlieg-Boerstra^{72

73

74}, Thomas Werfel⁷⁵, Margitta Worm⁷⁶, George Du Toit^{1

3}, Isabel Skypala^{77

78}

Affiliations

¹ Department of Women and Children's Health (Pediatric Allergy), Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK.
² Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.
³ Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK.
⁴ Department of Allergy and Clinical Immunology, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁵ Faculty of Medicine, Transylvania University, Brasov, Romania.
⁶ Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland.
⁷ Hospital General Universitario Gregorio Marañón, Madrid, Spain.
⁸ Gregorio Marañón Health Research Institute, Madrid, Spain.
⁹ Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.
¹⁰ Institut de Recerca Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
¹¹ Clinic for Dermatology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
¹² Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.
¹³ Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
¹⁴ Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹⁵ Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, University of Southern Denmark, Odense, Denmark.
¹⁶ Division of Pediatric Allergy, Department of Pediatrics, Koc University School of Medicine, Istanbul, Turkey.
¹⁷ McMaster University, Ontario, Hamilton, Canada.
¹⁸ Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital "Duilio Casula", University of Cagliari, Cagliari, Italy.
¹⁹ Paediatrics and Child Health, INFANT Centre, HRB-CRF, University College Cork, Cork, Ireland.
²⁰ Paediatrics and Child Health, Royal College of Surgeons in Ireland, Children's Health Ireland, Dublin, Ireland.
²¹ Department of Dermatology and Allergy Biederstein, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany.
²² Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.
²³ Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.
²⁴ Translational Medicine Program, Research Institute, Hospital for Sick Children, Ontario, Toronto, Canada.
²⁵ Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.
²⁶ Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria.
²⁷ Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St.Pölten, Austria.
²⁸ Allergy Department, Hospital Clinico San Carlos, Madrid, Spain.
²⁹ Facultad de Medicina, IdISSC, ARADyAL, Universidad Complutense, Madrid, Spain.
³⁰ Children's Hospital Colorado, University of Colorado School of Medicine, Colorado, Aurora, USA.
³¹ Department of Health Sciences, University of Florence, Florence, Italy.
³² Red Cross Children's Hospital and Kidsallergy Centre, Cape Town, South Africa.
³³ Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
³⁴ Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.
³⁵ Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
³⁶ Royal College of Surgeons in Ireland and Childrens Health Ireland, Dublin, Ireland.
³⁷ Faculty of Medical Sciences, School of Psychology, University of Surrey, Surrey, UK.
³⁸ Department of Clinical Immunology, Wrocław Medical University, ALL-MED Medical Research Institute, Wroclaw, Poland.
³⁹ Department of Dermatology/Allergology, Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
⁴⁰ Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloniki, Greece.
⁴¹ EAACI Patient Organisation Committee, Zurich, Switzerland.
⁴² Department of Medicine, Imperial College, London, UK.
⁴³ Department of Nutrition and Dietetics, Winchester University, Winchester, UK.
⁴⁴ Department of Medicine, KU Leuven, Leuven, Belgium.
⁴⁵ Department of Allergy, Hospital Universitario 12 de Octubre, Madrid, Spain.
⁴⁶ Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, Spain.
⁴⁷ Food Allergy Referral Centre, Padua University Hospital, Padua, Italy.
⁴⁸ Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
⁴⁹ Sachs Children and Youth Hospital, South Hospital, Stockholm, Sweden.
⁵⁰ Division of Allergy and Clinical Immunology, Department of Paediatrics, Federal University of São Paulo, São Paulo, Brazil.
⁵¹ Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland.
⁵² Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece.
⁵³ Lydia Becker Institute, University of Manchester, Manchester, UK.
⁵⁴ Department of Paediatrics, University of Melbourne, Victoria, Parkville, Australia.
⁵⁵ Department of Allergy and Immunology, Royal Children's Hospital, Victoria, Parkville, Australia.
⁵⁶ Population Allergy Research Group, Murdoch Children's Research Institute, Victoria, Parkville, Australia.
⁵⁷ EFA - European Federation of Allergy and Airways Diseases Patients' Associations, Brussels, Belgium.
⁵⁸ Allergy Clinic, Copenhagen University Hospital at Herlev-Gentofte, Copenhagen, Denmark.
⁵⁹ Department of Paediatric Allergy and Respiratory Medicine, University of Southampton, Southampton, UK.
⁶⁰ NIHR Southampton Biomedical Research Centre, Southampton, UK.
⁶¹ David Hide Asthma and Allergy Centre, St Mary Hospital, Isle of Wight, UK.
⁶² Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States.
⁶³ Child Life and Health, Centre for Inflammation Research, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK.
⁶⁴ Clinical Medicine, Griffith University, Queensland, Southport, Australia.
⁶⁵ Queensland Allergy Services Private Practice, Queensland, Southport, Australia.
⁶⁶ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁶⁷ Khoo Teck Puat-National University Children's Medical Institute, National University Health System (NUHS), Singapore, Singapore.
⁶⁸ Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁶⁹ Departments of Experimental Immunology and of Otorhinolaryngoloy, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
⁷⁰ Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado, Colorado, Aurora, USA.
⁷¹ Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, Atlanta, USA.
⁷² Department of Paediatrics, OLVG Hospital, Amsterdam, the Netherlands.
⁷³ Rijnstate Allergy Centre, Rijnstate Hospital, Arnhem, The Netherlands.
⁷⁴ Vlieg Dieticians, Private Practice for Dietary Management of Food Allergy, Arnhem, The Netherlands.
⁷⁵ Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany.
⁷⁶ Division of Allergy and immunology, Department of Dermatology, Venerology and Allergology, Charité Universitätsmedizin Berlin, Berlin, Germany.
⁷⁷ Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK.
⁷⁸ Department of Inflammation and Repair, Imperial College, London, UK.

PMID: 37815205
DOI: 10.1111/all.15902

EAACI guidelines on the diagnosis of IgE-mediated food allergy

Alexandra F Santos et al. Allergy. 2023 Dec.

. 2023 Dec;78(12):3057-3076.

doi: 10.1111/all.15902. Epub 2023 Oct 10.

Authors

Affiliations

¹ Department of Women and Children's Health (Pediatric Allergy), Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK.
² Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.
³ Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK.
⁴ Department of Allergy and Clinical Immunology, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁵ Faculty of Medicine, Transylvania University, Brasov, Romania.
⁶ Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland.
⁷ Hospital General Universitario Gregorio Marañón, Madrid, Spain.
⁸ Gregorio Marañón Health Research Institute, Madrid, Spain.
⁹ Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.
¹⁰ Institut de Recerca Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
¹¹ Clinic for Dermatology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
¹² Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.
¹³ Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
¹⁴ Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹⁵ Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, University of Southern Denmark, Odense, Denmark.
¹⁶ Division of Pediatric Allergy, Department of Pediatrics, Koc University School of Medicine, Istanbul, Turkey.
¹⁷ McMaster University, Ontario, Hamilton, Canada.
¹⁸ Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital "Duilio Casula", University of Cagliari, Cagliari, Italy.
¹⁹ Paediatrics and Child Health, INFANT Centre, HRB-CRF, University College Cork, Cork, Ireland.
²⁰ Paediatrics and Child Health, Royal College of Surgeons in Ireland, Children's Health Ireland, Dublin, Ireland.
²¹ Department of Dermatology and Allergy Biederstein, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany.
²² Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.
²³ Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.
²⁴ Translational Medicine Program, Research Institute, Hospital for Sick Children, Ontario, Toronto, Canada.
²⁵ Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.
²⁶ Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria.
²⁷ Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St.Pölten, Austria.
²⁸ Allergy Department, Hospital Clinico San Carlos, Madrid, Spain.
²⁹ Facultad de Medicina, IdISSC, ARADyAL, Universidad Complutense, Madrid, Spain.
³⁰ Children's Hospital Colorado, University of Colorado School of Medicine, Colorado, Aurora, USA.
³¹ Department of Health Sciences, University of Florence, Florence, Italy.
³² Red Cross Children's Hospital and Kidsallergy Centre, Cape Town, South Africa.
³³ Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
³⁴ Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.
³⁵ Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
³⁶ Royal College of Surgeons in Ireland and Childrens Health Ireland, Dublin, Ireland.
³⁷ Faculty of Medical Sciences, School of Psychology, University of Surrey, Surrey, UK.
³⁸ Department of Clinical Immunology, Wrocław Medical University, ALL-MED Medical Research Institute, Wroclaw, Poland.
³⁹ Department of Dermatology/Allergology, Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
⁴⁰ Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloniki, Greece.
⁴¹ EAACI Patient Organisation Committee, Zurich, Switzerland.
⁴² Department of Medicine, Imperial College, London, UK.
⁴³ Department of Nutrition and Dietetics, Winchester University, Winchester, UK.
⁴⁴ Department of Medicine, KU Leuven, Leuven, Belgium.
⁴⁵ Department of Allergy, Hospital Universitario 12 de Octubre, Madrid, Spain.
⁴⁶ Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, Spain.
⁴⁷ Food Allergy Referral Centre, Padua University Hospital, Padua, Italy.
⁴⁸ Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
⁴⁹ Sachs Children and Youth Hospital, South Hospital, Stockholm, Sweden.
⁵⁰ Division of Allergy and Clinical Immunology, Department of Paediatrics, Federal University of São Paulo, São Paulo, Brazil.
⁵¹ Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland.
⁵² Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece.
⁵³ Lydia Becker Institute, University of Manchester, Manchester, UK.
⁵⁴ Department of Paediatrics, University of Melbourne, Victoria, Parkville, Australia.
⁵⁵ Department of Allergy and Immunology, Royal Children's Hospital, Victoria, Parkville, Australia.
⁵⁶ Population Allergy Research Group, Murdoch Children's Research Institute, Victoria, Parkville, Australia.
⁵⁷ EFA - European Federation of Allergy and Airways Diseases Patients' Associations, Brussels, Belgium.
⁵⁸ Allergy Clinic, Copenhagen University Hospital at Herlev-Gentofte, Copenhagen, Denmark.
⁵⁹ Department of Paediatric Allergy and Respiratory Medicine, University of Southampton, Southampton, UK.
⁶⁰ NIHR Southampton Biomedical Research Centre, Southampton, UK.
⁶¹ David Hide Asthma and Allergy Centre, St Mary Hospital, Isle of Wight, UK.
⁶² Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States.
⁶³ Child Life and Health, Centre for Inflammation Research, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK.
⁶⁴ Clinical Medicine, Griffith University, Queensland, Southport, Australia.
⁶⁵ Queensland Allergy Services Private Practice, Queensland, Southport, Australia.
⁶⁶ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁶⁷ Khoo Teck Puat-National University Children's Medical Institute, National University Health System (NUHS), Singapore, Singapore.
⁶⁸ Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁶⁹ Departments of Experimental Immunology and of Otorhinolaryngoloy, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
⁷⁰ Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado, Colorado, Aurora, USA.
⁷¹ Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, Atlanta, USA.
⁷² Department of Paediatrics, OLVG Hospital, Amsterdam, the Netherlands.
⁷³ Rijnstate Allergy Centre, Rijnstate Hospital, Arnhem, The Netherlands.
⁷⁴ Vlieg Dieticians, Private Practice for Dietary Management of Food Allergy, Arnhem, The Netherlands.
⁷⁵ Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany.
⁷⁶ Division of Allergy and immunology, Department of Dermatology, Venerology and Allergology, Charité Universitätsmedizin Berlin, Berlin, Germany.
⁷⁷ Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK.
⁷⁸ Department of Inflammation and Repair, Imperial College, London, UK.

PMID: 37815205
DOI: 10.1111/all.15902

Abstract

This European Academy of Allergy and Clinical Immunology guideline provides recommendations for diagnosing IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Food allergy diagnosis starts with an allergy-focused clinical history followed by tests to determine IgE sensitization, such as serum allergen-specific IgE (sIgE) and skin prick test (SPT), and the basophil activation test (BAT), if available. Evidence for IgE sensitization should be sought for any suspected foods. The diagnosis of allergy to some foods, such as peanut and cashew nut, is well supported by SPT and serum sIgE, whereas there are less data and the performance of these tests is poorer for other foods, such as wheat and soya. The measurement of sIgE to allergen components such as Ara h 2 from peanut, Cor a 14 from hazelnut and Ana o 3 from cashew can be useful to further support the diagnosis, especially in pollen-sensitized individuals. BAT to peanut and sesame can be used additionally. The reference standard for food allergy diagnosis is the oral food challenge (OFC). OFC should be performed in equivocal cases. For practical reasons, open challenges are suitable in most cases. Reassessment of food allergic children with allergy tests and/or OFCs periodically over time will enable reintroduction of food into the diet in the case of spontaneous acquisition of oral tolerance.

Keywords: basophil activation test; diagnosis; food allergy; oral food challenges; skin prick test; specific IgE.

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References

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EAACI guidelines on the diagnosis of IgE-mediated food allergy

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EAACI guidelines on the diagnosis of IgE-mediated food allergy

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