Fish allergy

Fish allergy is an immune hypersensitivity to proteins found in fish. Symptoms can be either rapid or gradual in onset. The latter can take hours to days to appear. The former may include anaphylaxis, a potentially life-threatening condition which requires treatment with epinephrine. Other presentations may include atopic dermatitis or inflammation of the esophagus.[4] Fish is one of the eight common food allergens, responsible for 90% of allergic reactions to foods: cow's milk, eggs, wheat, shellfish, peanuts, tree nuts, fish, and soy beans.[5]

Fish allergy
Raw salmon steaks
Frequency~1.5% (self-reported, developed world)[1][2][3]

Unlike early childhood allergic reactions to milk and eggs, which often lessen as the children age, fish allergy tends to first appear in school-age children and persist in adulthood.[6][7] Strong predictors for adult-persistence are anaphylaxis, high fish-specific serum immunoglobulin E (IgE) and robust response to the skin prick test. It is unclear if the early introduction of fish to the diet of babies aged 4–6 months decreases the risk of later development of fish allergy. Adult onset of fish allergy is common in workers in the fish catching and processing industry.[8][9]

Signs and symptoms

Food allergies in general usually have a fast onset (from seconds to one hour). Symptoms may include: rash, hives, itching of mouth, lips, tongue, throat, eyes, skin, or other areas, swelling of lips, tongue, eyelids, or the whole face, difficulty swallowing, runny or congested nose, hoarse voice, wheezing, shortness of breath, diarrhea, abdominal pain, lightheadedness, fainting, nausea, or vomiting.[10] Symptoms of allergies vary from person to person and may vary from incident to incident.[10] Serious danger regarding allergies can begin when the respiratory tract or blood circulation is affected. The former can be indicated by wheezing, a blocked airway and cyanosis, the latter by weak pulse, pale skin, and fainting. When these symptoms occur the allergic reaction is called anaphylaxis.[10] Anaphylaxis occurs when IgE antibodies are involved, and areas of the body that are not in direct contact with the food become affected and show severe symptoms.[10][11] Untreated, this can proceed to vasodilation, a low blood pressure situation called anaphylactic shock, and death (very rare).[6][11]

Causes

Eating fish

The cause is typically the eating of fish or foods that contain fish. Once an allergic reaction has occurred it usually remains a lifelong sensitivity.[7] Briefly, the immune system overreacts to proteins found in fish. The allergic reaction to shellfish and crustaceans such as lobster and shrimp is to a different protein - tropomyosin - so there is no cross-reactivity between fish and shellfish allergy.[12][13][14]

'Hidden' allergen - a fish parasite

The food-borne parasite Anisakis is a genus of nematodes known to infect fish. Anisakis are directly infective to humans when infected fish is consumed raw or slightly processed, as for cerviche, causing a condition call anisakiasis, and in addition, can cause an allergic reaction to nematode proteins, even if the infected fish has been frozen or cooked. Allergic reactions can include hives, asthma and true anaphylactic reactions.[7][15][16]

Occupational exposure

An industry review conducted in 1990 estimated that 28.5 million people worldwide were engaged in some aspect of the seafood industry: fishing, aquaculture, processing and industrial cooking. Men predominate in fishing, women in processing facilities.[8] Exposure to fish allergenic proteins includes inhalation of wet aerosols from fresh fish handling, inhalation of dry aerosols from fishmeal processing, and dermal contact through skin breaks and cuts.[8][9] Prevalence of seafood-induced adult asthma is on the order of 10% (higher for crustaceans and lower for fish). Prevalence of skin allergy reactions, often characterized by itchy rash, range from 3% to 11%. The fish-induced health outcomes are mainly due to the protein parvalbumin causing an IgE mediated immune system response.[8][9]

Exercise as a contributing factor

There is a condition called food-dependent, exercise-induced anaphylaxis. Exercise can trigger hives and more severe symptoms of an allergic reaction. For some people with this condition, exercise alone is not sufficient, nor consumption of a food to which they are mildly allergic sufficient, but when the food in question is consumed within a few hours before high intensity exercise, the result can be anaphylaxis. Fish are specifically mentioned as a causative food.[17][18][19] One theory is that exercise is stimulating the release of mediators such as histamine from IgE-activated mast cells.[19] Two of the reviews postulate that exercise is not essential for the development of symptoms, but rather that it is one of several augmentation factors, citing evidence that the culprit food in combination with alcohol or aspirin will result in a respiratory anaphylactic reaction.[17][19]

Mechanisms

Allergic response

Conditions caused by food allergies are classified into three groups according to the mechanism of the allergic response:[20]

  1. IgE-mediated (classic) – the most common type, manifesting acute changes that occur shortly after eating, and may progress to anaphylaxis
  2. Non-IgE mediated – characterized by an immune response not involving immunoglobulin E; may occur hours to days after eating, complicating diagnosis
  3. IgE and non-IgE-mediated – a hybrid of the above two types

Allergic reactions are hyperactive responses of the immune system to generally innocuous substances, such as proteins in the foods we eat. Why some proteins trigger allergic reactions while others do not is not entirely clear, although in part thought to be due to resistance to digestion. Because of this, intact or largely intact proteins reach the small intestine, which has a large presence of white blood cells involved in immune reactions.[21] The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.[22] The pathophysiology of allergic responses can be divided into two phases. The first is an acute response that occurs immediately after exposure to an allergen. This phase can either subside or progress into a "late-phase reaction" which can substantially prolong the symptoms of a response, and result in more tissue damage.

In the early stages of acute allergic reaction, lymphocytes previously sensitized to a specific protein or protein fraction react by quickly producing a particular type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called mast cells and basophils. Both of these are involved in the acute inflammatory response.[23] Activated mast cells and basophils undergo a process called degranulation, during which they release histamine and other inflammatory chemical mediators called (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation, mucous secretion, nerve stimulation, and smooth-muscle contraction. This results in runny nose, itchiness, shortness of breath, and potentially anaphylaxis. Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to particular body systems; asthma is localized to the respiratory system while eczema is localized to the skin.[23]

After the chemical mediators of the acute response subside, late-phase responses can often occur due to the migration of other white blood cells such as neutrophils, lymphocytes, eosinophils, and macrophages to the initial reaction sites. This is usually seen 2–24 hours after the original reaction.[24] Cytokines from mast cells may also play a role in the persistence of long-term effects. Late-phase responses seen in asthma are slightly different from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.[25]

In addition to IgE-mediated responses, fish allergy can manifest as atopic dermatitis, especially in infants and young children. Some will display both, so that a child could react to an oral food challenge with allergic symptoms, followed a day or two later with a flare up of atopic dermatitis and/or gastrointestinal symptoms, including allergic eosinophilic esophagitis.

Fish allergenic proteins

The protein parvalbumin has been identified as the major allergen causing fish allergy (but not shellfish allergy, which is caused by tropomyosin).[26][27][28][29] Parvalbumin is resistant to heat and enzymatic digestion, so cooking does not diminish its allergenic potency, nor do digestive enzymes.[30] Bony fishes manifest β-parvalbumin whereas cartilaginous fishes such as sharks and rays manifest α-parvalbumin; allergenicity to bony fishes has a low cross-reactivity to cartilaginous fishes.[27] In addition to β-parvalbumin, fish enolase, aldolase and collagen can also trigger allergic reactions.[13][30] Fish collagen is widely used in the food industry in foods such as gummy candies, jelly beans or marshmallows. It may also be marketed as a dietary supplement ingredient or as an inactive ingredient in pharmaceutical products. Standardized skin tests that incorporate parvalbumin for fish sensitivity will miss collagen allergy. People may be allergic to parvalbumin, collagen, or both.[31]

Non-allergic intolerance

There is a reaction from consuming fish that mimics an allergic reaction. Scombroid is a foodborne illness that results from high in histamine due to inappropriate storage or processing. Histamine is the main natural chemical responsible for true allergic reactions, hence the confusion with fish allergy. Scombroid symptom onset is typically 10-30 minutes after consumption, and may include flushed skin, headache, itchiness, blurred vision, abdominal cramps and diarrhea. Fish commonly implicated include tuna, mackerel, sardine, anchovy, herring, bluefish, amberjack and marlin. These fish naturally have high levels of the amino acid histidine, which is converted to histamine when bacterial growth occurs during improper storage. Subsequent cooking, smoking, canning or freezing does not eliminate the histamine.[7][32][33][34]

Diagnosis

Diagnosis of fish allergy is based on the person's history of allergic reactions, skin prick test and measurement of fish-specific serum immunoglobulin E (IgE or sIgE). Confirmation is by double-blind, placebo-controlled food challenges.[12] Self-reported fish allergy often fails to be confirmed by food challenge.[1]

Prevention

When fish is introduced to a baby's diet is thought to affect risk of developing allergy, but there are contradictory recommendations. Reviews of allergens in general stated that introducing solid foods at 4–6 months may result in the lowest subsequent allergy risk.[35] Reviews specific to when fish is introduced to the diet state that fish consumption during the first year of life reduce the subsequent risks of eczema and allergic rhinitis,[35][36] but maternal consumption during pregnancy had no such effect.[36]

Treatment

Treatment for accidental ingestion of fish products by allergic individuals varies depending on the sensitivity of the person. An antihistamine such as diphenhydramine may be prescribed. Sometimes prednisone will be prescribed to prevent a possible late phase Type I hypersensitivity reaction.[37] Severe allergic reactions (anaphalaxis) may require treatment with an epinephrine pen, i.e., an injection device designed to be used by a non-healthcare professional when emergency treatment is warranted.[38] Unlike for egg allergy, for which there is active research on trying oral immunotherapy (OIT) to desensitize people to egg allergens,[39] a 2015 review mentioned that there are no published clinical trials evaluating oral immunotherapy for fish allergy.[14]

Prognosis

Unlike milk and egg allergies, fish allergy usually persists into adulthood.[2][7]

Epidemiology

Incidence and prevalence are terms commonly used in describing disease epidemiology. Incidence is newly diagnosed cases, which can be expressed as new cases per year per million people. Prevalence is the number of cases alive, expressible as existing cases per million people during a period of time.[40] Strong predictors for adult-persistent allergy are anaphylactic symptoms as a child, high fish-specific serum IgE and robust response to the skin prick test. Reviews cite self-reported fish allergy in range of 0 to 2.5% in the general population.[1][2][3] Self-reported allergy prevalence is always higher than food-challenge confirmed allergy, which two reviews put at 0.1% and 0.3%, respectively.[1][30]

Society and culture

Whether food allergy prevalence is increasing or not, food allergy awareness has definitely increased, with impacts on the quality of life for children, their parents and their immediate caregivers.[41][42][43][44] In the United States, the Food Allergen Labeling and Consumer Protection Act of 2004 causes people to be reminded of allergy problems every time they handle a food package, and restaurants have added allergen warnings to menus. The Culinary Institute of America, a premier school for chef training, has courses in allergen-free cooking and a separate teaching kitchen.[45] School systems have protocols about what foods can be brought into the school. Despite all these precautions, people with serious allergies are aware that accidental exposure can easily occur at other peoples' houses, at school or in restaurants.[46] Food fear has a significant impact on quality of life.[43][44]

Regulation of labelling
An example of a list of allergens in a food item

In response to the risk that certain foods pose to those with food allergies, some countries have responded by instituting labeling laws that require food products to clearly inform consumers if their products contain major allergens or byproducts of major allergens among the ingredients intentionally added to foods. Nevertheless, there are no labeling laws to mandatory declare the presence of trace amounts in the final product as a consequence of cross-contamination.[47][48][49][50][51]

Ingredients intentionally added

In the United States, the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA) requires companies to disclose on the label whether a packaged food product contains any of these eight major food allergens, added intentionally: cow's milk, peanuts, eggs, shellfish, fish, tree nuts, soy and wheat.[47] This list originated in 1999 from the World Health Organisation Codex Alimentarius Commission.[52] To meet FALCPA labeling requirements, if an ingredient is derived from one of the required-label allergens, then it must either have its "food sourced name" in parentheses, for example "Casein (milk)," or as an alternative, there must be a statement separate but adjacent to the ingredients list: "Contains milk" (and any other of the allergens with mandatory labeling).[47][49] The European Union requires listing for those eight major allergens plus molluscs, celery, mustard, lupin, sesame and sulfites.[48]

FALCPA applies to packaged foods regulated by the FDA, which does not include poultry, most meats, certain egg products, and most alcoholic beverages.[53] However, some meat, poultry, and egg processed products may contain allergenic ingredients. These products are regulated by the Food Safety and Inspection Service (FSIS), which requires that any ingredient be declared in the labeling only by its common or usual name. Neither the identification of the source of a specific ingredient in a parenthetical statement nor the use of statements to alert for the presence of specific ingredients, like "Contains: milk", are mandatory according to FSIS.[50][51] FALCPA also does not apply to food prepared in restaurants.[54][55] The EU Food Information for Consumers Regulation 1169/2011 – requires food businesses to provide allergy information on food sold unpackaged, for example, in catering outlets, deli counters, bakeries and sandwich bars.[56]

gollark: Sure, I guess?
gollark: You can do anything if you believe in yourself!
gollark: > || A horse with a really big tumor on it's back? ||||the "tumor" is mere optical illusion||
gollark: ||camels are not real, it is a horse||
gollark: It's actually not, it's my wallpaper, which was generated by some haskell program.

See also

References
  1. Nwaru BI, Hickstein L, Panesar SS, Roberts G, Muraro A, Sheikh A (August 2014). "Prevalence of common food allergies in Europe: a systematic review and meta-analysis". Allergy. 69 (8): 992–1007. doi:10.1111/all.12423. PMID 24816523.
  2. Sharp MF, Lopata AL (June 2014). "Fish allergy: in review". Clin Rev Allergy Immunol. 46 (3): 258–71. doi:10.1007/s12016-013-8363-1. PMID 23440653.
  3. Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, Sigurdardottir ST, Lindner T, Goldhahn K, Dahlstrom J, McBride D, Madsen C (September 2007). "The prevalence of food allergy: a meta-analysis". J. Allergy Clin. Immunol. 120 (3): 638–46. doi:10.1016/j.jaci.2007.05.026. PMID 17628647.
  4. National Report of the Expert Panel on Food Allergy Research, NIH-NIAID 2003 "June 30 2003.pdf" (PDF). Archived from the original (PDF) on 2006-10-04. Retrieved 2006-08-07.
  5. "Food Allergy Facts" Archived 2012-10-06 at the Wayback Machine Asthma and Allergy Foundation of America
  6. Urisu A, Ebisawa M, Ito K, Aihara Y, Ito S, Mayumi M, Kohno Y, Kondo N (2014). "Japanese Guideline for Food Allergy 2014". Allergol Int. 63 (3): 399–419. doi:10.2332/allergolint.14-RAI-0770. PMID 25178179.
  7. Prester L (2016). "Seafood Allergy, Toxicity, and Intolerance: A Review". J Am Coll Nutr. 35 (3): 271–83. doi:10.1080/07315724.2015.1014120. PMID 26252073.
  8. Lopata AL, Jeebhay MF (June 2013). "Airborne seafood allergens as a cause of occupational allergy and asthma". Curr Allergy Asthma Rep. 13 (3): 288–97. doi:10.1007/s11882-013-0347-y. PMID 23575656.
  9. Jeebhay MF, Robins TG, Lehrer SB, Lopata AL (September 2001). "Occupational seafood allergy: a review". Occup Environ Med. 58 (9): 553–62. doi:10.1136/oem.58.9.553. PMC 1740192. PMID 11511741.
  10. MedlinePlus Encyclopedia: Food allergy
  11. Sicherer SH, Sampson HA (2014). "Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment". J Allergy Clin Immunol. 133 (2): 291–307. doi:10.1016/j.jaci.2013.11.020. PMID 24388012.
  12. Tong WS, Yuen AW, Wai CY, Leung NY, Chu KH, Leung PS (2018). "Diagnosis of fish and shellfish allergies". J Asthma Allergy. 11: 247–60. doi:10.2147/JAA.S142476. PMC 6181092. PMID 30323632.
  13. Ruethers T, Taki AC, Johnston EB, Nugraha R, Le TT, Kalic T, McLean TR, Kamath SD, Lopata AL (August 2018). "Seafood allergy: A comprehensive review of fish and shellfish allergens". Mol. Immunol. 100: 28–57. doi:10.1016/j.molimm.2018.04.008. PMID 29858102.
  14. Thalayasingam M, Lee BW (2015). "Fish and shellfish allergy". Chem Immunol Allergy. 101: 152–61. doi:10.1159/000375508. PMID 26022875.
  15. Nieuwenhuizen NE, Lopata AL (August 2014). "Allergic reactions to Anisakis found in fish". Curr Allergy Asthma Rep. 14 (8): 455. doi:10.1007/s11882-014-0455-3. PMID 25039016.
  16. Audicana MT, Kennedy MW (2008). "Anisakis Simplex: From Obscure Infectious Worm to Inducer of Immune Hypersensitivity". Clinical Microbiology Reviews. 21 (2): 360–79. doi:10.1128/CMR.00012-07. PMC 2292572. PMID 18400801.
  17. Feldweg AM (2017). "Food-Dependent, Exercise-Induced Anaphylaxis: Diagnosis and Management in the Outpatient Setting". J Allergy Clin Immunol Pract. 5 (2): 283–288. doi:10.1016/j.jaip.2016.11.022. PMID 28283153.
  18. Pravettoni V, Incorvaia C (2016). "Diagnosis of exercise-induced anaphylaxis: current insights". J Asthma Allergy. 9: 191–198. doi:10.2147/JAA.S109105. PMC 5089823. PMID 27822074.
  19. Kim CW, Figueroa A, Park CH, Kwak YS, Kim KB, Seo DY, Lee HR (2013). "Combined effects of food and exercise on anaphylaxis". Nutr Res Pract. 7 (5): 347–51. doi:10.4162/nrp.2013.7.5.347. PMC 3796658. PMID 24133612.
  20. "Food allergy". NHS Choices. 16 May 2016. Retrieved 31 January 2017. A food allergy is when the body's immune system reacts unusually to specific foods
  21. Food Reactions. Allergies Archived 2010-04-16 at the Wayback Machine. Foodreactions.org. Kent, England. 2005. Accessed 27 Apr 2010.
  22. Mayo Clinic. Causes of Food Allergies. Archived 2010-02-27 at the Wayback Machine April 2010.
  23. Janeway, Charles; Paul Travers; Mark Walport; Mark Shlomchik (2001). Immunobiology; Fifth Edition. New York and London: Garland Science. pp. e–book. ISBN 978-0-8153-4101-7. Archived from the original on 2009-06-28.
  24. Grimbaldeston MA, Metz M, Yu M, Tsai M, Galli SJ (2006). "Effector and potential immunoregulatory roles of mast cells in IgE-associated acquired immune responses". Curr. Opin. Immunol. 18 (6): 751–60. doi:10.1016/j.coi.2006.09.011. PMID 17011762.
  25. Holt PG, Sly PD (2007). "Th2 cytokines in the asthma late-phase response". Lancet. 370 (9596): 1396–8. doi:10.1016/S0140-6736(07)61587-6. PMID 17950849. S2CID 40819814.
  26. Leung NY, Wai CY, Shu S, Wang J, Kenny TP, Chu KH, Leung PS (June 2014). "Current immunological and molecular biological perspectives on seafood allergy: a comprehensive review". Clin Rev Allergy Immunol. 46 (3): 180–97. doi:10.1007/s12016-012-8336-9. PMID 23242979.
  27. Stephen JN, Sharp MF, Ruethers T, Taki A, Campbell DE, Lopata AL (March 2017). "Allergenicity of bony and cartilaginous fish - molecular and immunological properties". Clin. Exp. Allergy. 47 (3): 300–12. doi:10.1111/cea.12892. PMID 28117510.
  28. Sharp MF, Stephen JN, Kraft L, Weiss T, Kamath SD, Lopata AL (February 2015). "Immunological cross-reactivity between four distant parvalbumins-Impact on allergen detection and diagnostics". Mol. Immunol. 63 (2): 437–48. doi:10.1016/j.molimm.2014.09.019. PMID 25451973.
  29. Fernandes TJ, Costa J, Carrapatoso I, Oliveira MB, Mafra I (October 2017). "Advances on the molecular characterization, clinical relevance, and detection methods of Gadiform parvalbumin allergens". Crit Rev Food Sci Nutr. 57 (15): 3281–296. doi:10.1080/10408398.2015.1113157. PMID 26714098.
  30. Kourani E, Corazza F, Michel O, Doyen V (2019). "What Do We Know About Fish Allergy at the End of the Decade?". J Investig Allergol Clin Immunol. 29 (6): 414–21. doi:10.18176/jiaci.0381. PMID 30741635.
  31. Kalic T, Kamath SD, Ruethers T, Taki AC, et al. (May 2020). "Collagen-An Important Fish Allergen for Improved Diagnosis". J Allergy Clin Immunol Pract. doi:10.1016/j.jaip.2020.04.063. PMID 32389794.
  32. "Food Poisoning from Marine Toxins - Chapter 2 - 2018 Yellow Book". Centers for Disease Control and Prevention (CDC). 2017. Retrieved 15 July 2020.
  33. Ridolo E, Martignago I, Senna G, Ricci G (October 2016). "Scombroid syndrome: it seems to be fish allergy but... it isn't". Curr Opin Allergy Clin Immunol. 16 (5): 516–21. doi:10.1097/ACI.0000000000000297. PMID 27466827.
  34. Feng C, Teuber S, Gershwin ME (February 2016). "Histamine (Scombroid) Fish Poisoning: a Comprehensive Review". Clin Rev Allergy Immunol. 50 (1): 64–69. doi:10.1007/s12016-015-8467-x. PMID 25876709.
  35. Ferraro V, Zanconato S, Carraro S (May 2019). "Timing of Food Introduction and the Risk of Food Allergy". Nutrients. 11 (5). doi:10.3390/nu11051131. PMC 6567868. PMID 31117223.
  36. Zhang GQ, Liu B, Li J, Luo CQ, Zhang Q, Chen JL, Sinha A, Li ZY (March 2017). "Fish intake during pregnancy or infancy and allergic outcomes in children: A systematic review and meta-analysis". Pediatr Allergy Immunol. 28 (2): 152–61. doi:10.1111/pai.12648. PMID 27590571.
  37. Tang AW (2003). "A practical guide to anaphylaxis". Am Fam Physician. 68 (7): 1325–1332. PMID 14567487.
  38. The EAACI Food Allergy and Anaphylaxis Guidelines Group (August 2014). "Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology". Allergy. 69 (8): 1026–45. doi:10.1111/all.12437. PMID 24909803. S2CID 11054771.
  39. Romantsik, O; Tosca, MA; Zappettini, S; Calevo, MG (20 April 2018). "Oral and sublingual immunotherapy for egg allergy". The Cochrane Database of Systematic Reviews. 4: CD010638. doi:10.1002/14651858.CD010638.pub3. PMC 6494514. PMID 29676439.
  40. "Incidence and Prevalence" Advanced Renal Education Program (Accessed 17 October 2017).
  41. Ravid NL, Annunziato RA, Ambrose MA, Chuang K, Mullarkey C, Sicherer SH, Shemesh E, Cox AL (2015). "Mental health and quality-of-life concerns related to the burden of food allergy". Psychiatr. Clin. North Am. 38 (1): 77–89. doi:10.1016/j.psc.2014.11.004. PMID 25725570.
  42. Morou Z, Tatsioni A, Dimoliatis ID, Papadopoulos NG (2014). "Health-related quality of life in children with food allergy and their parents: a systematic review of the literature". J Investig Allergol Clin Immunol. 24 (6): 382–95. PMID 25668890.
  43. Lange L (2014). "Quality of life in the setting of anaphylaxis and food allergy". Allergo J Int. 23 (7): 252–260. doi:10.1007/s40629-014-0029-x. PMC 4479473. PMID 26120535.
  44. van der Velde JL, Dubois AE, Flokstra-de Blok BM (2013). "Food allergy and quality of life: what have we learned?". Curr Allergy Asthma Rep. 13 (6): 651–61. doi:10.1007/s11882-013-0391-7. PMID 24122150. S2CID 326837.
  45. Culinary Institute of America Allergen-free oasis comes to the CIA (2017)
  46. Shah E, Pongracic J (2008). "Food-induced anaphylaxis: who, what, why, and where?". Pediatr Ann. 37 (8): 536–41. doi:10.3928/00904481-20080801-06. PMID 18751571.
  47. "Food Allergen Labeling and Consumer Protection Act of 2004". FDA. August 2, 2004. Archived from the original on 2011-02-02.
  48. "Food allergen labelling and information requirements under the EU Food Information for Consumers Regulation No. 1169/2011: Technical Guidance" (April 2015).
  49. FDA (14 December 2017). "Have Food Allergies? Read the Label". Retrieved 14 January 2018.
  50. "Food Ingredients of Public Health Concern" (PDF). United States Department of Agriculture. Food Safety and Inspection Service. 7 March 2017. Retrieved 16 February 2018.
  51. "Allergies and Food Safety". United States Department of Agriculture. Food Safety and Inspection Service. 1 December 2016. Retrieved 16 February 2018.
  52. Allen KJ, Turner PJ, Pawankar R, Taylor S, Sicherer S, Lack G, Rosario N, Ebisawa M, Wong G, Mills EN, Beyer K, Fiocchi A, Sampson HA (2014). "Precautionary labelling of foods for allergen content: are we ready for a global framework?". World Allergy Organ J. 7 (1): 1–14. doi:10.1186/1939-4551-7-10. PMC 4005619. PMID 24791183.
  53. FDA (18 December 2017). "Food Allergies: What You Need to Know". Retrieved 12 January 2018.
  54. Roses JB (2011). "Food allergen law and the Food Allergen Labeling and Consumer Protection Act of 2004: falling short of true protection for food allergy sufferers". Food Drug Law J. 66 (2): 225–42, ii. PMID 24505841.
  55. FDA (18 July 2006). "Food Allergen Labeling And Consumer Protection Act of 2004 Questions and Answers". Retrieved 12 March 2018.
  56. "Allergy and intolerance: guidance for businesses". Archived from the original on 2014-12-08. Retrieved 2014-12-12.
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