Allergy & Immunology

Food Allergies

Advertisment

Managing Food Allergies in Adolescents and Young Adults

patient care perspectives by Edwin Kim, MD, MS
Overview

The transition time from childhood through adolescence and young adulthood can present unique challenges and opportunities in the management of food allergies. Edwin Kim, MD, MS, discusses clinical and patient-focused considerations for health care providers as they help patients and their families manage food allergies throughout these years.

Expert Commentary
“It is important for us to have the right perspective and goals of therapy. For example, if the goal is having a minimal treatment burden with adequate protection vs getting to the point where the patient can eat the food in their diet to a small degree, we need to make sure that our treatments are actually aligned with their wishes.”
— Edwin Kim, MD, MS

We estimate that approximately 80% of childhood milk and egg allergies are outgrown. Recent research suggests, however, that it may take longer to outgrow some food allergies than we used to think. We used to tell patients with milk and egg allergies, “By the time you reach elementary school, they’re probably going to be gone.” But we are finding more children and adolescents going into middle school and even high school who still have those allergies but outgrow them later. And then, of course, there are the 20% of those who do not outgrow them.

 

We also have to consider the more persistent allergies, such as peanut and tree nut allergies. We estimate that only approximately 20%, at most, will outgrow these. Therefore, although these allergies are diagnosed early, they can be very relevant in an older age group. Further, there are some allergies, particularly seafood allergies such as fish and shellfish allergies, that we typically think of as developing more in adulthood, so in older ages. Therefore, it is important for us to think about how all these allergies can affect that age group.

 

As individuals move into adolescence, measures such as allergen avoidance start to become much more relevant to the patients themselves. A younger child in preschool or even elementary school may not totally appreciate the restrictions and precautions. But once they reach adolescence, that burden transfers slowly but steadily to the patient. This is where we may really see a disconnect (ie, we will have parents who are very anxious and are pursuing treatments for their child but are experiencing more pushback from the child). The social aspects also now become very important in these age groups. The idea of fitting in and not wanting to be different becomes really meaningful.

 

It is important for us to have the right perspective and goals of therapy. For example, if the goal is having a minimal treatment burden with adequate protection vs getting to the point where the patient can eat the food in their diet to a small degree, we need to make sure that our treatments are actually aligned with their wishes.

 

Unfortunately, when it comes to the life-threatening and life-ending reactions, it does seem disproportionately focused on this teenage age group. This may be because this group may be more likely to take chances and less likely to be compliant with carrying their epinephrine autoinjector. Also, for those with asthma, perhaps the recognition of those asthma symptoms may not be as good in those teenage years, and asthma is one of the biggest risk factors for having a more severe reaction to food allergens.

 

Early on, a lot of our immunotherapy studies started in a broader pediatric age group, from 4 to 18 years of age. Some efficacy was seen, but there was a growing understanding that younger patients perhaps have more malleable immune systems. Sure enough, the data suggested that intervening early is more effective. It does seem like we can achieve higher thresholds and perhaps longer-lasting therapy, but, in that process, this older age group has somewhat been ignored.

 

I do think that it will be important for our therapies to take what we have learned from younger age groups and determine how we can get those same results for adolescents/teenagers and young adults (ie, college-aged individuals). The use of biologics in this older age group may be helpful, especially because of their intermittent use. Any daily treatment is going to be hard, especially in this age group.

References

Davis CM, Gupta RS, Aktas ON, Diaz V, Kamath SD, Lopata AL. Clinical management of seafood allergy. J Allergy Clin Immunol Pract. 2020;8(1):37-44. doi:10.1016/j.jaip.2019.10.019

 

Iweala OI, Choudhary SK, Commins SP. Food allergy. Curr Gastroenterol Rep. 2018;20(5):17. doi:10.1007/s11894-018-0624-y

 

Lee ECK, Trogen B, Brady K, Ford LS, Wang J. The natural history and risk factors for the development of food allergies in children and adults. Curr Allergy Asthma Rep. 2024;24(3):121-131. doi:10.1007/s11882-024-01131-3

 

Leonard SA. Debates in allergy medicine: baked milk and egg ingestion accelerates resolution of milk and egg allergy. World Allergy Organ J. 2016;9:1. doi:10.1186/s40413-015-0089-5

 

Newman KL, Chater A, Knibb RC. Beliefs about food allergies in adolescents aged 11-19 years: a systematic review. Clin Transl Allergy. 2022;12(4):e12142. doi:10.1002/clt2.12142

 

Roberts G, Bahnson HT, Du Toit G, et al. Defining the window of opportunity and target populations to prevent peanut allergy. J Allergy Clin Immunol. 2023;151(5):1329-1336. doi:10.1016/j.jaci.2022.09.042

 

Soller L, Williams BA, Mak R, et al. Safety and effectiveness of bypassing oral immunotherapy buildup with an initial phase of sublingual immunotherapy for higher-risk food allergy. J Allergy Clin Immunol Pract. 2024 Feb 27:S2213-2198(24)00198-3. doi:10.1016/j.jaip.2024.02.024

 

Warren CM, Jiang J, Gupta RS. Epidemiology and burden of food allergy. Curr Allergy Asthma Rep. 2020;20(2):6. doi:10.1007/s11882-020-0898-7

Edwin Kim, MD, MS

    Associate Professor of Pediatrics and Medicine
    Chief, Division of Pediatric Allergy and Immunology
    Director, UNC Food Allergy Initiative
    Director, UNC Allergy and Immunology Fellowship Program
    University of North Carolina School of Medicine
    Chapel Hill, NC
Advertisment