Sample Food Allergy Guideline

Today’s post is the second in a series of sample clinical guidelines.  All of these sample guidelines will be placed under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort!  If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.

I wrote about food allergies previously on JailMedicine in “Food Allergies: Sorting Out Truth from Fiction” (found here). Since then, I have had more email requests for a Food Allergy guideline than all other sample guidelines put together.  It is clearly a BIG issue in corrections.

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on personal footwear. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. In a correctional setting, the ability to differentiate true food allergies from simple food aversion is essential. On the one hand, jails and prisons do not want someone with a true food allergy to be served that food and suffer an allergic reaction. On the other hand, some inmates who have no true food allergy may use the claim of an allergy to avoid foods they do not like, to gain status among other inmates and to manipulate staff. The goal is to accurately identify those individuals with a true food allergy and exclude those who do not have a true food allergy.

Reference: The main reference for this guideline is “Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report.” National Institute of Allergy and Infectious Diseases. U.S. Department of Health and Human Services, National Institutes of Health. December 2010. Readers with questions or wanting more detail should refer to this document.

Definitions.

IgE Food Allergy refers to an IgE mediated allergic reaction to the glycoproteins in certain foods. These allergic reactions are characterized by urticarial rash, angioedema, breathing difficulties, and/or anaphylaxis. IgE food allergies are most common in infants but many of these patients lose their allergy over time. Most adults who report a food allergy are found by diagnostic testing to not, in fact, have an allergy. Most cases of true food allergy in adults are to peanuts, treenuts, shellfish, or fish. An estimated 100 people die each year from acute allergic reactions, most commonly to peanut or tree nuts. Almost all of these patients have had previous anaphylactic reactions to the food in question.

Non-IgE food allergy refers to reactions to food that are not mediated by IgE, such as Celiac Disease. Non-IgE food reactions tend to have different symptoms, be more insidious and difficult to diagnose than IgE reactions.

Food intolerance refers to non-allergic reactions to food, including:
1. Food poisoning due to a toxin.
2. Side effects of substances found in some foods (example, headache caused by tyramine in wine or racing heart caused by caffeine).
3. Lack of digestive enzymes, such as lactose intolerance and patients needing pancreatic enzyme replacement.
4. Food aversion in which patients have a psychological revulsion for certain foods but experience no problems when they ingest that food unknowingly.

Evaluation of stated food allergy.
1. History. Most cases of true food allergy can be verified by history. Patients with a credible history of food allergy should be referred to see a medical practitioner. A complete history includes:
a. Any allergist or other medical practitioner who has treated the patient for the food allergy.
b. Any food allergy testing done.
c. Any emergency department visits for anaphylaxis caused by food allergy.
d. Any Epi-pen prescriptions.
e. Verification of a history of food allergy may require medical personnel to obtain relevant medical records and/or directly contact previous medical providers.
2. Physical Examination. Physical examination is usually not helpful in the evaluation of IgE food allergy unless the patient is currently having an allergic reaction.
3. Lab testing.
a. Food specific IgE immunoassay testing (sometimes called RAST testing) may be ordered if clinically appropriate. The IgE test is sensitive but not specific, meaning that it can be relied upon to exclude a true allergy when negative. When positive, there is still a statistical chance that the patient does NOT have a true allergy. Patients with a positive test result but whose history is not convincing may be referred to an allergist for a definitive food challenge test.
b. Allergy testing should not be ordered for foods that are not served at the correctional institution (for example, shellfish).

Prevention. Since the vast majority of food allergy related fatalities are caused by IgE reactions to peanuts or tree nuts, the best strategy to prevent serious food allergy reactions is to eliminate peanuts and tree nuts from the menu offered to inmates.

Treatment. A patient with a positive IgE immunoassay but no documented history of anaphylaxis may require only a diet free of the particular food. Any other treatments for such a patient will depend on observed signs and symptoms. Treatment of a patient with a history of anaphylaxis should is two pronged, avoiding the food in question and being prepared for an acute allergic emergency.
1. Food avoidance. A diet free of the offending food should be ordered for the patient. Care should be taken to not allow a patient with a true food allergy to inadvertently purchase foods containing the allergen off of commissary. For example, a patient with a true peanut allergy should not be allowed to purchase Snickers Bars. Consideration should be made about housing inmates with a true food allergy in a setting where they might become inadvertently exposed to the allergen. Patients with a true food allergy may not appropriate candidates for inmate worker status if this involves working around the allergenic food.
2. Preparation for an allergic emergency. Inmates with documented anaphylaxic reactions to a food may require an Epi-pen to be kept in the housing area where the patient is housed. All correctional officers assigned to that housing area should be taught how to administer the Epi-pen in an emergency.

Other References.

1. Adkinson: Middleton’s Allergy: Principles and Practice, 7th ed. Chapter 65—Adverse Reactions to Foods
2. Food Allergy: Diagnosis and Management. Primary Care: Clinics in Office Practice. Vol. 35, issue 1 (March 2008).
3. Rakel: Integrative Medicine, 2nd ed. Chapter 86—Adverse Food Reactions and the Elimination Diet
4. Uptodate. Diagnostic evaluation of food allergy. October 20, 2015

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