The optimal diagnostic workup for children with suspected food allergy

Food allergy is defined as an abnormal immunologic reaction to food proteins that causes an adverse clinical reaction. In addition to well-known acute allergic reactions and anaphylaxis triggered by immunoglobulin E antibody-mediated immune responses to food proteins, there is an increasing recognition of cell-mediated disorders such as eosinophilic esophagitis and food protein-induced enterocolitis syndrome. More than 90% of food allergies in childhood are caused by eight foods: cow's milk, hen's egg, soy, peanuts, tree nuts, wheat, fish, and shellfish. The diagnostic workup for a child with suspected food allergy includes a detailed medical history, physical examination, food allergy screening tests, and responses to an elimination diet and an oral food challenge. None of the screening tests, alone or in combination, can definitely diagnose or exclude a food allergy. Novel diagnostic methods including those that focus on immune responses to specific food proteins or epitopes of specific proteins are under active study. Unconventional diagnostic methods are increasingly used, but they lack scientific rationale, standardization, and reproducibility. In selected cases, such as eosinophilic esophageal gastroenteropathies or food protein-induced gastroesophageal reflux disease, invasive procedures are mandatory for an accurate diagnosis. Properly done, an oral food challenge is still the gold standard in the diagnostic workup. An incorrect diagnosis is likely to result in unnecessary dietary restrictions, which, if prolonged, may adversely affect the child's nutritional status and growth.