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Food allergy and the gut

Key Points

  • Food allergy affects 6–8% of children <5 years old and 3–4% of the general population in developed countries; incidence of peanut allergy has increased considerably over the past decade

  • Food allergy results from a lack of oral tolerance, a state of systemic unresponsiveness to ingested soluble antigens mediated mainly by regulatory T cells in the gastrointestinal tract

  • Food reactions can have IgE-mediated, non-IgE-mediated or a combination of IgE-mediated and non-IgE-mediated pathophysiology involving the skin, gastrointestinal tract, respiratory tract and/or cardiovascular system

  • Double-blind, placebo-controlled food challenge remains the gold standard for diagnosing food allergy

  • Dietary elimination of offending foods is the current standard of care; future therapies focus on specific food immunotherapy via oral, sublingual and epicutaneous routes

  • Most childhood food allergies resolve with age, with the exception of peanut and tree nut allergies that tend to be lifelong

Abstract

Food allergy develops as a consequence of a failure in oral tolerance, which is a default immune response by the gut-associated lymphoid tissues to ingested antigens that is modified by the gut microbiota. Food allergy is classified on the basis of the involvement of IgE antibodies in allergic pathophysiology, either as classic IgE, mixed pathophysiology or non-IgE-mediated food allergy. Gastrointestinal manifestations of food allergy include emesis, nausea, diarrhoea, abdominal pain, dysphagia, food impaction, protein-losing enteropathy and failure to thrive. Childhood food allergy has a generally favourable prognosis, whereas natural history in adults is not as well known. Elimination of the offending foods from the diet is the current standard of care; however, future therapies focus on gradual reintroduction of foods via oral, sublingual or epicutaneous food immunotherapy. Vaccines, modified hypoallergenic foods and modification of the gut microbiota represent additional approaches to treatment of food allergy.

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Figure 1: Differential immune responses in the gut (oral tolerance) and skin (IgE sensitization and food allergy) using peanut allergy as an example.
Figure 2: Approach to diagnosis and management of food allergy.

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Acknowledgements

The authors thank S. Koletzko, Division of Paediatric Gastroenterology and Hepatology at the Kinderpoliklinik, and Dr von Haunersches Kinderspital at the Ludwig Maximilians University of Munich, Germany, for her helpful comments and suggestions.

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Correspondence to Anna Nowak-Wegrzyn.

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Nowak-Wegrzyn, A., Szajewska, H. & Lack, G. Food allergy and the gut. Nat Rev Gastroenterol Hepatol 14, 241–257 (2017). https://doi.org/10.1038/nrgastro.2016.187

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