Food Allergy Testing, Egg Sensitivity, and Flu Shots

The title here takes in a significant amount of material. Its intent is to get your attention to an old theme and to hopefully help with considerations of dealing with the need for a flu immunization (aka flu shot) in the face of egg sensitization (having a positive allergy test to egg).

A young African-American girl of 11 months presented upon the recommendation of her pulmonologist. The pulmonologist saw the need for a flu shot however there was some concern about a positive allergy test to egg. This little girl had a ‘Phadia Specific IgE’ set of food allergy panels performed for about 31 foods (the bill to the mother was >$800). The test was performed because of a concern for a constant runny nose. The child was tested to the usual suspects for food allergy in young children. The test array went significantly further. As I have talked about previously, because of the marketing of these allergy blood tests to include extra items (at more expense) these are in most cases irrelevent. Many of the foods tested are not part of a young child’s diet. The test included foods that this young lady of 11 months has never ingested; lobster, shrimp, tree nuts, shrimp, and clams to name a few. So in the end mother was at risk to pay for information that was not relevent to the child’s situation or exposures. There is also the argument within this case regarding the pursuit of a food allergy for the complaint of a runny nose in an 11 month old child.

The test for egg was 0.51 kU/L. The cutoff for a negative response is <0.35 kU/L. When you look at the literature for critical cut-off levels for doing an egg challenge, this value would indicate that the child will have a high probability of a negative and successful egg challenge.

Now the real kicker. As we all know there is no better test for a food allergy than the challenge; give the food and see what happens. We do have to be careful depending upon the history of previous reactions for those challenges. In this baby’s history she had been eating scrambled eggs without any problems. There was no history of a cause/effect relationship with egg exposure.

Now let us add in the variable of the flu shot. The flu shot contains egg protein. The recommendations from the CDC and the AAP are to not give the flu shot if there is a history of a severe reaction. This pertains to what happened when egg was ingested. It does not pertain to the presence or size of an allery test for egg. In this case, cooked eggs have been ingested without any reactions. So in my opinion, the history of egg exposure and having no serious reactions with that exposure should clear the way for the flu immunization. For those children who have serious reactions to egg but can eat heated egg products, there is a need for considering a desensitization for the fluogen. The egg in the vaccine is more like cooked egg (scrambled, hard boiled, over easy etc) than heated egg (cakes, cookies, muffins, and waffles). The history of eating products with heated egg should not be considered a ‘safe’ for those with serious egg reactions.

The children need to be immunized for this upcoming flu season.

My humble opinion,

Fred Leickly

September 24, 2009 · fleickly · 4 Comments
Posted in: Allergy Testing, Egg Allergy, Food Allergies, Immunizations, Phadia Allergy Tests

4 Responses

  1. Eva - October 8, 2009

    Are you recommending that kids get the H1N1 vaccine in addition to the regular flu shot? I’ve heard some negative comments that the vaccine has been
    ” too rushed” etc…

  2. fleickly - October 8, 2009

    Yes I am recommending the H1N1 vaccination. I plan to get it when it is offered to me. This would be the second time I will be immunized against the swine flu. Back in the last century there was another ‘swine’ flu scare’. I was in medical school and I received the ‘swine flu’ shot then. Fortunately the 1976 swine flu pandemic was minimal (perhaps due to the massive immunization program) and there were concerns about the vaccine then. That was more than 30 years ago. The science of vaccine development has evolved tremendously.
    The time line for development has been swift, however the vaccine is here and so is the H1N1. Hopefully the impact of the H1N1 will be minimized in the population with the immunization program.
    FEL

  3. Amy - February 8, 2010

    Hello Dr. Fleickly,
    My name is Amy and would like to ask you a question about egg/dairy protein allergies thought be to in my children (ages 1.5 and 3.5 years) old. When my oldest was only 3 months old she was rushed to Riley with blood in her stool and a very distended belly. After many tests it was concluded that she has a dairy allergy and that if I wanted to continue breastfeeding I would need to remove the allergyn from my diet, etc. We scheduled an appointment with a Fishers allergist which ran several blood tests coming back that although those tests were negitive, she was thought to have a dairy and possibly egg protein allergy and to start the elimination diet. For our daughter this has worked thur far, athough we have never been 100% sure if it’s egg or dairy protein she is allergic to? (Nursed until 15 months, removing all daily/egg, and she has remained on elim. diet still to date). We have tested her with daily/egg a few times and have had skin reactions both times.

    Flash forward to our son being born, Northpoint peds. suggest we go with elim. diet from the start with him, since sister already had the same allergies, why test so early on newborn. However, our son has remained a very fussy child, and continue to have skin problems (i.e. eczema, nummular, red cheeks), several ear infections resulting in eustachian tubes @ 11 months of age. (Nursed until 12 months, never a very good nurser, and still continues the elim. diet)

    My question for you doctor is this, is there any news tests that could give us exact answers for our children? Also could it be possible that my son is allergic to something else in addition to dairy/egg. or maybe he isn’t allergic to those proteins but something else? I’ve read that sometimes when children have allergies they will know that food hurts them and actually refuse it, maybe he was allergic to the soy in my milk? If there are some type of new tests, should we give them a shot or should we just continue with the elim. diets until they reach an older age?

    ps- both children have always received their flu shots and are ok, except usually develop a skin rash.

    Thank you so much for your time in this matter,
    Amy King

  4. fleickly - February 9, 2010

    You have quite a few things going on. Let me try to go over them one by one.
    First, your oldest child. The occurence of blood in the stool at 3 months of life- not really an allergy, this is not an IgE mediated reaction. The allergy skin test and the allergy blood test will be negative with this condition. This is a milk protein enteropathy- an immune reaction to milk (can be soy too) possibly due to IgG or IgM. I have not heard of egg being part of this condition. Soy has been implicated. I would expect the ‘allergy’ work-up for this to be negative because we know that the reaction is not working in a way that classic allergy tests can predict. Children usually outgrow the milk protein enteropathy after a year or so of avoidance. So the early tests were negative and she developed a positive skin test over time? I would have used a specific IgE to egg white and to milk/casein/whey (blood test) after a year of avoidance. If the values are below the critical cut-off- a food challenge to egg/milk could be done to confirm an allergic reaction or the lack of any reactivity.
    Second, your son- the eczema could be related to food. If it is indeed nummular, probablly it is not food related. Usually the more severe children with atopic eczema tend to have clinically relevant food sensitivities. There are many other things that can trigger and aggravate atopic eczema, foods may be a part of a much larger picture. The recurrent ear infection issue would be a most unusual and indeed rare manifestation of a food allergy. In the ENT literature this is frequently talked about, however when it is actually looked at in well designed studies, the risk factor is not there.
    In my experience, food allergy is not subtle:children have classic allergic/type I hypersensitivity symptoms with exposure and with re-exposure you will always recreate the same symptoms. A positive test for a food does not necessarily mean that the child is allergic- the test tells us that antibody has been made. The relevance of that result is determeined by the history and the result of food challenges. A child who has experienced anaphylactic shock, vomiting, urticaria, and flares of atopic eczema may realize that a specific food exposure will always cause these symptoms. That realization is a function of the maturation of the child. Certainly some foods can be detected in breast milk. Remember too that food can cause reactions that are not IgE mediated.
    A skin test performed after a careful history/examination helps determine a type I hypersensitivy reaction (IgE)-classic allergy. The chance of that test being falsely negative is <6%.
    This has been quite a long answer for you, I hope it helps.
    Thanks for looking at the website and thanks for the interesting questions.
    FEL