Allergen Bureau Conference - Vincent St Aubyn Crump
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Update on Food AllergyUpdate on Food AllergyFood Allergen BureauFood Allergen Bureau
Vincent St Vincent St AubynAubyn CrumpCrump FRCP(UK), FRACPFRCP(UK), FRACP
Auckland Allergy ClinicAuckland Allergy ClinicOctober 14, 2008October 14, 2008
B cell T lymphocyte
Food protein
IgEAntibody
Mast cell/ Basophil
Sensitization
Elicitation/ Reactivity
ALLERGY
Skin- itchiness, flushing, hives, swelling, eczemaGI- nausea, vomiting, abdominal pain, diarrheaRespiratory- tightness, runny nose, wheezing,throat closing/swellingVascular- dizziness, low blood pressure, heart irregularities, shock
AnaphylaxisFood
•Subjective
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UKNew Zealand
AustraliaRepublic of Ireland
CanadaPeru
Costa RicaBrazilUSA
ParaguayUruguayPanama
KuwaitSouth Africa
MaltaFinland
LebanonKenya
GermanyFranceJapan
ThailandSweden
Hong KongPhilippines
BelgiumAustria
IranArgentina
EstoniaNigeria
SpainChile
SingaporeMalaysiaPortugal
UzbekistanOman
ItalyPakistan
LatviaPolandAlgeria
South KoreaMorocco
MexicoEthiopia
IndiaTaiwanRussiaChina
GreeceGeorgia
RomaniaAlbania
Indonesia
0 5 10 15 20 25 30 35 40Prevalence of asthma symptoms (%)
12-month prevalence of asthma symptoms
in ISAAC
ISAAC Steering CommitteeLancet 1998
Admissions for Anaphylaxis in NHS Hospitals in the UK
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0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
1989 '94-'95
peanut sensitizationPeanut Allergy
Increasing Prevalence of Peanut Allergy in the UK
Isle of Wight cohort study
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Atopic IcebergAtopic IcebergClinical Allergy
•Eczema•Asthma
•Hay Fever•Food Allergy
Sensitized Atopic
Latent Allergy(Potential to develop the disease)
or
Adverse reaction to a Food(Any abnormal reaction from food ingestion)
Non-toxic
ToxicScombroid fish poisoning
Bacterial food poisoning poisoning
Psychologic intolerancePavlovian conditioning
oFood aversion
Food Allergy(Immune)
Food Intolerance(non-Immune)
MetabolicLactose Intolerance
PharmacologicCaffeine ‘anxiety’Histamine sinsitivitySalicylate sensitivity
IdiosyncraticSulfite “sensitivity’
IgE-Mediated(Immediate)AnaphylaxisUrticariaAsthmaAtopic DermOral Allergy
Mixed(IgE & non-IgE)[Intermediate]
Esinophilicoesophagitis
Non- IgECoeliac
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The adverse reactions to foodsThe adverse reactions to foodsPsychological / EmotionalPsychological / Emotional
Psychological burden associated with genuine food allergy & intoPsychological burden associated with genuine food allergy & intoleranceslerancesPsychological (conditioned) food responsesPsychological (conditioned) food responses
Acute Acute urticariaurticaria (hives(hives) ) -- 20% in kids20% in kidsEczemaEczema –– up to 60%up to 60%Oral Allergy SyndromeOral Allergy Syndrome --40% hay fever sufferers40% hay fever sufferersCoeliacCoeliac DiseaseDiseaseAsthma Asthma –– 5%5%
SulfiteSulfite--inducedinducedGastrointestnalGastrointestnal SyndromesSyndromes
EosinophilicEosinophilic EsophagitisEsophagitisProtein Protein enterocolitisenterocolitisLactose IntoleranceLactose Intolerance
Anaphylaxis Anaphylaxis –– 35%35%Fear & PhobiasFear & PhobiasDeath Death –– risk < ?risk < ?
Prevalence of Food Allergy in young Prevalence of Food Allergy in young childrenchildren
Food Food CountryCountry______________Children__________________________________ _____ ______________Children__________________________________ _____ Adult Adult
USA AUS FRA NOR CHINA DEN* UUSA AUS FRA NOR CHINA DEN* USASA
Milk 2.5% 2.0% 1.1% 3.2% Milk 2.5% 2.0% 1.1% 3.2% 1.7% 0.65 0.3%1.7% 0.65 0.3%
Egg 1.3% 3.2% 0.6% 2.0% Egg 1.3% 3.2% 0.6% 2.0% 3.0% 1.6% 0.2%3.0% 1.6% 0.2%
Peanut 0.8% 1.9% 0.7% Peanut 0.8% 1.9% 0.7% -- 0.3% 0.3% 0.6%0.3% 0.3% 0.6%
Tree nuts 0.2% 0.3% 0.7% Tree nuts 0.2% 0.3% 0.7% -- -- -- 0.5%0.5%
Fish 0.1% 0.07 Fish 0.1% 0.07 -- -- 0.3% 0.3% -- 0.4%0.4%
Shellfish 0.1% Shellfish 0.1% -- 1.4% 1.4% -- -- -- 2.0%2.0%
Sesame Sesame -- 0.4% 0.4% -- -- -- -- --
Overall 6% 7.77 6% Overall 6% 7.77 6% -- 5.2% 5.2% -- 3.7%3.7%* Point prevalence* Point prevalence
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Food Allergies causing Anaphylaxis Food Allergies causing Anaphylaxis in Canberra (60.9% of cases):in Canberra (60.9% of cases):
Foods % Median AgeFoods % Median AgePeanut / tree nuts/ seeds: 26 Peanut / tree nuts/ seeds: 26 77
Peanut 14.4 Peanut 14.4 44Tree nut / seed 11.4 Tree nut / seed 11.4 1313Peanut + Tree nut/seed 12.3 Peanut + Tree nut/seed 12.3 55
Egg 11.4 Egg 11.4 33Fruit / Vegetables 11.1 Fruit / Vegetables 11.1 3030Wheat 6.7 Wheat 6.7 3131Crustaceans 6.2 Crustaceans 6.2 3434Scaly fish 5.1 Scaly fish 5.1 13 13 CowCow’’s milk 4.4 s milk 4.4 33Soy 1.9 Soy 1.9 2020Meat 1.6 Meat 1.6 2929GelatineGelatine 0.9 0.9 5454Alginate (seaweed) thickener 0.2 Alginate (seaweed) thickener 0.2 4040
Mandatory Food Allergen/Food Mandatory Food Allergen/Food Intolerance Labelling ANZFAIntolerance Labelling ANZFA
Cereals containing gluten and their products (wheat, rye, Cereals containing gluten and their products (wheat, rye, barley, oats and spelt and their hybridised strains) barley, oats and spelt and their hybridised strains) CrustaceaCrustacea (e.g. crayfish, crabs, prawns) and their (e.g. crayfish, crabs, prawns) and their products products Egg and egg products Egg and egg products Fish and fish products Fish and fish products Milk and milk products Milk and milk products Nuts and sesame seeds and their products Nuts and sesame seeds and their products Peanuts and soybeans, and their products Peanuts and soybeans, and their products Added sulphites in concentrations of 10mg/kg or more Added sulphites in concentrations of 10mg/kg or more
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Mandatory labelling contd.Mandatory labelling contd.
Food products containing these substances Food products containing these substances must be declaredmust be declared when present as: when present as: An ingredient An ingredient An ingredient of a compound ingredient An ingredient of a compound ingredient A food additive or component of a food additive A food additive or component of a food additive A processing aid or component of a processing A processing aid or component of a processing aid aid These allergens can be declared in the These allergens can be declared in the ingredient list ingredient list
Mandatory food allergens in EUMandatory food allergens in EUcelerycelerycereals containing gluten (including wheat, rye, barley and oatscereals containing gluten (including wheat, rye, barley and oats) ) crustaceans (including prawns, crabs and lobsters) crustaceans (including prawns, crabs and lobsters) eggs eggs fish fish lupinlupinmilk milk molluscs (including mussels and oysters) molluscs (including mussels and oysters) mustardmustardnuts, such as almonds, hazelnuts, walnuts, Brazil nuts, cashews,nuts, such as almonds, hazelnuts, walnuts, Brazil nuts, cashews, pecans, pecans, pistachios and macadamia nuts pistachios and macadamia nuts peanuts peanuts sesame seeds sesame seeds soybeans soybeans sulphur dioxide and sulphites (preservatives used in some foods sulphur dioxide and sulphites (preservatives used in some foods and drinks) and drinks) at levels above 10mg per kg or per litreat levels above 10mg per kg or per litre
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The The CoeliacCoeliac dilemmadilemma
The FSANZ standard for gluten The FSANZ standard for gluten free foodfree food
Final Assessment Report, (P264) has now been passed by the FoodFinal Assessment Report, (P264) has now been passed by the Food Standards Standards Council and the food regulations changed to state the following:Council and the food regulations changed to state the following:Standard 1.2.8 Claims in relation to gluten content of foodStandard 1.2.8 Claims in relation to gluten content of foodA claim to the effect that a food is A claim to the effect that a food is gluten freegluten free must not be made in relation to a food must not be made in relation to a food unless the food contains nounless the food contains no(a) detectable gluten; and(a) detectable gluten; and(b) no (b) no ––(i) oats or their products; or(i) oats or their products; or(ii) cereals containing gluten that have been malted, or their p(ii) cereals containing gluten that have been malted, or their productsroducts
A claim to the effect that a food has a A claim to the effect that a food has a low glutenlow gluten content must not be made in content must not be made in relation to a food unless the food contains no more than 20 mg grelation to a food unless the food contains no more than 20 mg gluten per 100g of the luten per 100g of the food.food.The major change has been in the Low Gluten claim, which now makThe major change has been in the Low Gluten claim, which now makes a maximum es a maximum level of 20mg gluten/100g of food as the sole criteria for makinlevel of 20mg gluten/100g of food as the sole criteria for making a low gluten claim. g a low gluten claim. The prohibition on oats and malt has also been removed for the lThe prohibition on oats and malt has also been removed for the low gluten claim.ow gluten claim.The NZ Society of Gastroenterologists and the NZ Dietetic AssociThe NZ Society of Gastroenterologists and the NZ Dietetic Association have stated ation have stated that the that the Low Gluten StandardLow Gluten Standard is generally considered the appropriate treatment is generally considered the appropriate treatment standard for those with standard for those with coeliaccoeliac disease.disease.
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What is the main purpose of laws What is the main purpose of laws on food allergens?on food allergens?
To prevent death?To prevent death?oror
To improve quality of life?To improve quality of life?
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Facts on Peanut AllergyFacts on Peanut AllergyAbout 1About 1--2 % in children in developed countries2 % in children in developed countriesCommonest food causing deathCommonest food causing deathPeanut deaths are rare Peanut deaths are rare vsvs children road deathschildren road deathsIn UK prevalence of sensitization up from 1.3 to 3.2% from In UK prevalence of sensitization up from 1.3 to 3.2% from ’’89 to 89 to ‘‘959575% of reactions occur on 175% of reactions occur on 1stst known exposureknown exposureSensitization probably doesnSensitization probably doesn’’t occur in t occur in uteroutero,,As little as 100ug can cause As little as 100ug can cause rxnrxn (kissing)(kissing)Usually associated with other food allergiesUsually associated with other food allergiesCurrent preventative measures not workingCurrent preventative measures not workingMore common in siblings (7%), Heritability=81%More common in siblings (7%), Heritability=81%Only ~20% outgrown & probably recurOnly ~20% outgrown & probably recurVery high toll on Quality of life of familiesVery high toll on Quality of life of families
Should peanuts be banned in Should peanuts be banned in schools?schools?
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Arguments Arguments againstagainst banning banning Peanuts from SchoolsPeanuts from Schools
Technically impracticalTechnically impracticalMay cause undue burden on unaffectedMay cause undue burden on unaffectedSlippery slopeSlippery slope-- ban other 7 foods? Which?ban other 7 foods? Which?May create false sense of securityMay create false sense of securityNot a real world situationNot a real world situationFor:For: Make life easier for all Peanut allergic Make life easier for all Peanut allergic and familiesand families
GoatGoat’’s feta cheese anaphylaxiss feta cheese anaphylaxis
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Emerging Problem?Emerging Problem?
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Kiwi fruit Allergy Kiwi fruit Allergy New Zealand started growing the fruit for New Zealand started growing the fruit for export since 1906, export since 1906, but the first report of allergic reaction to kiwi but the first report of allergic reaction to kiwi occurred relatively late in 1981occurred relatively late in 1981..Risk factors:Risk factors: Birch allergy & Latex allergy Birch allergy & Latex allergy Age:Age: It occurs at all ages, but is more It occurs at all ages, but is more common in adults than in children common in adults than in children In one study in Spain (a birchIn one study in Spain (a birch--free area) 43 free area) 43
patients with kiwi allergypatients with kiwi allergy 21% of the patients 21% of the patients were not allergic to pollens & 46% of patients were not allergic to pollens & 46% of patients experienced systemic (generalized / experienced systemic (generalized / anaphylactic) reaction. They had no anaphylactic) reaction. They had no pollinosispollinosis
Clinical Manifestations of kiwi Clinical Manifestations of kiwi allergyallergy
Oral Allergy Syndrome, which is itching of the Oral Allergy Syndrome, which is itching of the inside of the mouth, tongue & pharynx, inside of the mouth, tongue & pharynx, associated with itching and swelling of the lips. associated with itching and swelling of the lips. This is probably the commonest manifestation of This is probably the commonest manifestation of kiwi allergy. 83% in a Swedish study kiwi allergy. 83% in a Swedish study Acute Acute UrticariaUrticaria (hives) (hives) –– 18% 18% RhinoconjunctivitisRhinoconjunctivitis (itchy eyes & nose) (itchy eyes & nose) –– 6% 6% Difficulty swallowing, nausea, vomiting Difficulty swallowing, nausea, vomiting -- 4% 4% Asthma Asthma –– 4% 4% AnaphylaxisAnaphylaxis
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Severity of kiwi allergySeverity of kiwi allergy
In another Swedish study of 361 kiwi allergic In another Swedish study of 361 kiwi allergic patients, the severity was graded as follows:patients, the severity was graded as follows:Mild Symptoms Mild Symptoms –– 40%40%Moderate Moderate –– 32%32%Severe Severe –– 28%28%Foods associated with Kiwi allergy:Foods associated with Kiwi allergy:
strongly to Apple and Hazelnut,strongly to Apple and Hazelnut,moderately to Carrot, Potato, and Avocado, and moderately to Carrot, Potato, and Avocado, and
weakly to Wheat and Rye flour, Pineapple and weakly to Wheat and Rye flour, Pineapple and Papaya, and their enzymes Papaya, and their enzymes bromelainbromelain and and papainpapain
Oral Allergy SyndromeOral Allergy Syndrome
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Foods that cause OASFoods that cause OASFoods associated with birch pollen allergyFoods associated with birch pollen allergy
Fruits:Fruits:Apples*Apples*,, kiwi*kiwi*, , apricot*, peach*apricot*, peach*, pear, plum, prune, cherry, nectarine, pear, plum, prune, cherry, nectarine
VegetablesVegetablesCarrot, Carrot, celery*celery*, parsnip,, , parsnip,, potato*potato*, tomato, , tomato, ParsleyParsley, coriander, green pepper, fennel, dill, coriander, green pepper, fennel, dillPeanut, peas, lentils, Peanut, peas, lentils, beans*beans*,,
NutsNutsHazelnut*Hazelnut*, Walnut, Almond, Walnut, Almond
Seeds: SunflowerSeeds: Sunflower
Foods associated with grass pollen allergyFoods associated with grass pollen allergyOrange, kiwi, watermelon, melon,Orange, kiwi, watermelon, melon,tomato, potato, peanuttomato, potato, peanut
Foods associated with Olive pollen allergyFoods associated with Olive pollen allergyPear, Peach, kiwi, melon, nutPear, Peach, kiwi, melon, nut
* Reported to cause anaphylactic reac* Reported to cause anaphylactic reactiontion
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Fruit FamiliesFruit FamiliesRosaceaeRosaceae::
PrunoideaePrunoideae subfamilysubfamilyPeachPeachAlmondAlmondCherryCherry
PomoideaePomoideae subfamilysubfamilyAppleApplePearPear
RosoideaeRosoideae subfamilysubfamilyStrawberryStrawberryBlackberryBlackberry
About 50% of patients allergic to 1 fruit from the About 50% of patients allergic to 1 fruit from the RosaceaeRosaceae family family will have crosswill have cross--reactivity to another member of the familyreactivity to another member of the family
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The Carrot Family or Parsley family The Carrot Family or Parsley family ((UmbelliferaeUmbelliferae or or ApiaceaeApiaceae))
ParsleyParsleyCorianderCorianderFennelFennelCuminCuminAniseAniseDillDillChervilChervilCarawayCarawayCarrotCarrotParsnipParsnipCelery & CeleriacCelery & Celeriac
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Risk Factors for Anaphylaxis in Risk Factors for Anaphylaxis in OASOAS
History of anaphylaxis to related foodHistory of anaphylaxis to related foodReactions to cooked formsReactions to cooked formsCommercial SPT positiveCommercial SPT positiveNo sensitization to related pollenNo sensitization to related pollenEstablished allergy to peachEstablished allergy to peachOAS from latexOAS from latex--fruit cluster (banana, kiwi)fruit cluster (banana, kiwi)
Treatment: Discuss Epipen & Pollen ITTreatment: Discuss Epipen & Pollen IT
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Celery AllergyCelery AllergyCelery is one of the most common foods to cause oral Celery is one of the most common foods to cause oral allergy syndrome in adults in countries such as allergy syndrome in adults in countries such as Switzerland, France and Germany. Switzerland, France and Germany. Allergy to celeriac (the celery root) is more common than Allergy to celeriac (the celery root) is more common than to celery (the stalks of the plant), but both can to celery (the stalks of the plant), but both can sometimes cause severe reactions.sometimes cause severe reactions.Symptoms vary from mild ones, such as oral allergy Symptoms vary from mild ones, such as oral allergy
syndrome, to anaphylactic shock. Some reports suggest syndrome, to anaphylactic shock. Some reports suggest that celery spice is as likely to cause a reaction in that celery spice is as likely to cause a reaction in sensitive people as raw celery.sensitive people as raw celery.Since November 2005, food labelling rules require preSince November 2005, food labelling rules require pre--packed food sold in the UK, and the rest of the European packed food sold in the UK, and the rest of the European Union, to show clearly on the label if it contains celeryUnion, to show clearly on the label if it contains celery
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Mustard Allergy Alert Mustard Allergy Alert -- MorrisonsMorrisons Natural Natural Choice Tomato & Chicken Choice Tomato & Chicken FusiloniFusiloni
5th August 20085th August 2008In the UK In the UK MorrisonsMorrisons are recalling their are recalling their Natural Choice Tomato & Chicken Natural Choice Tomato & Chicken FusiloniFusiloni. As a result of a production error, . As a result of a production error, the wrong sauce has been used within the the wrong sauce has been used within the product, and contains a mustard ingredient product, and contains a mustard ingredient which has not been listed as an allergen which has not been listed as an allergen on the pack.on the pack.
SpicesSpices
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Baby Food LabelBaby Food LabelNo artificial colourings or flavourings No artificial colourings or flavourings Gluten free Gluten free Egg free Egg free Wheat free Wheat free Dairy free Dairy free Soy free Soy free Peanut free Peanut free No fillers or thickening agents No fillers or thickening agents No artificial preservatives No artificial preservatives Naturally tasty, no added salt or sugar Naturally tasty, no added salt or sugar
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Baby FoodBaby Food
Vegetables (Potatoes, Tomatoes, Vegetables (Potatoes, Tomatoes, SweetcornSweetcorn, Carrots, Pumpkin, Onion), , Carrots, Pumpkin, Onion), Water, LambWater, Lamb’’s Liver, Maize Thickener (1422), Bacon (Contains Soy) s Liver, Maize Thickener (1422), Bacon (Contains Soy) Ground Rice, Ground Rice, Spice ExtractSpice Extract
Ingredients:Ingredients: Water, Organic Carrots, Organic Tomato Paste, Organic Water, Organic Carrots, Organic Tomato Paste, Organic Cheddar Cheese (Pasteurized Organic Whole Milk, Cheese Culture, Cheddar Cheese (Pasteurized Organic Whole Milk, Cheese Culture, Enzymes) Organic Spaghetti (Organic Whole Wheat Durum Flour), OrEnzymes) Organic Spaghetti (Organic Whole Wheat Durum Flour), Organic ganic Whole Wheat Flour, Organic Onions, Organic Garbanzo Whole Wheat Flour, Organic Onions, Organic Garbanzo BeansBeans..
IngredientsWater, Vegetables (21%) (Yellow Split Peas, Carrots (7%), Onion, Potatoes (2.5%) Chicken (12%), Rice Noodles (7%), Maize Thickener (1422), Herb Extract, Pepper
IngredientsIngredientsWater, Vegetables (24%) (Carrots, Potatoes, Yellow Split Peas), Water, Vegetables (24%) (Carrots, Potatoes, Yellow Split Peas), Lamb Lamb (10%), Maize Thickener (1422), Maize Polenta, Ground Rice, (10%), Maize Thickener (1422), Maize Polenta, Ground Rice, Herb Herb
Less well known
Mustard AllergyMustard Allergy
Mustard allergens are heatMustard allergens are heat--resistant and resistant and resistant to enzymatic degradation, and resistant to enzymatic degradation, and therefore are not markedly affected by food therefore are not markedly affected by food processing. processing. In a study in France mustard is the fourth most In a study in France mustard is the fourth most important food allergen for children, after eggs, important food allergen for children, after eggs, peanuts, and cow milk. peanuts, and cow milk. Since November 2005 food labelling rules in the Since November 2005 food labelling rules in the
European Union requires labelling of mustard.European Union requires labelling of mustard.
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Mustard Allergy in FranceMustard Allergy in FranceIn study of near fatal anaphylaxis in FranceIn study of near fatal anaphylaxis in France
Celery 30%Celery 30%CrustaceaCrustacea 17%17%Fish 13%Fish 13%Peanuts 12%Peanuts 12%Mango 6%Mango 6%Mustard 3%Mustard 3%
Study of anaphylaxis in children in FranceStudy of anaphylaxis in children in FranceEgg 35%Egg 35%Peanut 24%Peanut 24%CowCow’’s milk 8%s milk 8%Mustard 6%Mustard 6%
Features of Mustard allergy in Features of Mustard allergy in children in Francechildren in France
53.3% started under age of 3 years53.3% started under age of 3 yearsAtopic eczema in 51.8%Atopic eczema in 51.8%UrticariaUrticaria (hives) & swelling 37%(hives) & swelling 37%Mustard in commercial baby foodsMustard in commercial baby foods3 infants breastfed until 11m & never 3 infants breastfed until 11m & never consumed mustard had +consumed mustard had +veve SPT to SPT to mustard aged 12mustard aged 12--18m18m
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Update on Food AllergyUpdate on Food AllergyFood Allergen BureauFood Allergen Bureau
Vincent St Vincent St AubynAubyn CrumpCrump FRCP(UK), FRACPFRCP(UK), FRACP
Auckland Allergy ClinicAuckland Allergy ClinicOctober 14, 2008October 14, 2008