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Food allergy in Sri Lanka – A comparative study

Open AccessPublished:November 23, 2022DOI:https://doi.org/10.1016/j.waojou.2022.100723

      Abstract

      Background

      The incidence of IgE mediated food allergy (FA) is increasing in the west. Cow's milk (CM), hen's egg, wheat, soy, peanut, tree nut, fish, and shellfish are responsible for 90% of food allergy in the west; however, local dietary habits may result in specific allergies. Data on food allergies in South Asia is scarce. The present study aims to evaluate the foods that cause immediate type hypersensitivity in Sri Lanka, and to compare with Asia and the developed west.

      Methods

      Records of patients referred to an Immunology clinic from 2010–January 2022 were reviewed. The diagnosis of food allergy was based on standard guidelines. Confirmation of the specific food implicated was based on the history and the presence of specific IgE or component resolved diagnostics by in vitro methods (Phadia ImmunoCap) or by skin prick testing with commercial extracts (Alk Abello). Prick to prick testing was performed for fruits and vegetables when commercial extracts were unavailable.

      Results

      Three hundred and forty-six patients were confirmed with food allergy. CM allergy (CMA) was the commonest (31.2%) followed by red meat allergy (27.7%) and food dependent exercise induced anaphylaxis (FDEIA) (17.9%). Allergy to alpha-gal crustaceans, eggs, gelatin, wheat, coconut milk, and mollusks were seen in 2–10% of patients.
      The onset of CMA was mainly in childhood. However, in 23/108 patients, onset was after 5 years, including 8 patients in adulthood, and in 14 of the 23, it was preceded by red meat allergy. Onset of primary red meat allergy was predominantly in children, but in 33/96 (34.3%) of patients, it was in adults. Most patients with alpha-gal allergy (21/29, 72.4%) had initial symptoms in childhood and adolescence.
      Anaphylaxis was diagnosed in 213 patients. FDEIA is the commonest cause (24.7%) followed by red meat allergy (23%), CMA (21.5%) and alpha-gal allergy (10.3%). Allergy to peanuts and fruits were rare.
      Patients with red meat allergy and/or CMA developed allergy, including anaphylaxis, to vaccines containing bovine/porcine products.

      Conclusion

      CM was the most common food allergy in children, but egg allergy was uncommon. Primary red meat allergy was the second most common, and was associated with allergy to vaccines containing bovine products, such as the measles, mumps and rubella (MMR) vaccine. Allergy to peanuts and fruits were rare. Primary red meat allergy may be responsible for late onset CMA.

      Keywords

      Introduction

      Food allergy is “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food”.
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      In contrast, non-allergic adverse reactions to foods may be the result of food intolerances or adverse physiologic reactions.
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      Food allergy: a practice parameter update - 2014.
      IgE mediated food allergies are the best characterized of food allergies, whose incidence is increasing in the west. IgE mediated food allergy may give rise to cutaneous (urticaria, angioedema), gastro intestinal (vomiting, diarrhoea and abdominal pain), cardiovascular (hypotension), and respiratory (oral allergy syndrome, stridor, wheeze, cough) symptoms and signs. Some of these patients will have anaphylaxis. Cow's milk (CM), egg, wheat, soy, peanut, tree nut, fish, and shellfish are responsible for 90% of food allergy in the west;
      • Sicherer S.H.
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      Food allergy: a review and update on epidemiology, pathogenesis, diagnosis, prevention, and management.
      however, local dietary habits may result in specific allergies, for example, sesame in Israel and buckwheat in Japan.
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      Middleton's Allergy 2-Volume Set.
      In East and Central Asian countries, the food triggers for severe allergic reactions are major components of the Asian diet: fish, shellfish, bird's nest, buckwheat, and royal jelly.
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      The epidemiology of food allergy in the global context.
      In Singapore, Thailand, and Hong Kong, shellfish is one of the most important food triggers of anaphylaxis in adults and children. Allergy to edible bird's nest from swiftlets has also been described in Singapore and Malaysia.
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      • Tang M.L.K.
      The epidemiology of food allergy in the global context.
      Data on food allergies in South Asia are scarce. In the EuroPrevall-INCO study conducted in 8 countries, the incidence of food allergy in adults in India was 1.3% with CM and apple being the commonest food allergens.
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      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      A meta-analysis showed the food allergens identified in India; Apple, fish, banana, cow's milk, melon, sesame, shrimp, tree nuts, chickpea, capsicum, Indian lentils, avocado, banana, beef, bulgur wheat, coconut, corn, eggplant, garlic, ginger, green peas, jalapeño peppers, kiwi, melon, rice, and tomato.
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      Prevalence of food allergies in South Asia.
      In addition, there are a few case reports of allergy to mango, mushroom, fenugreek, and chickpea.
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      • Wong G.W.
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      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      The data from Sri Lanka is meagre. Using a questionnaire in 449 school children in the Colombo District, 30% of the respondents believed they had a food allergy, of which pineapple was thought to be the commonest allergic food. In addition, rambutan (Nephelium lappaceum), tomato, bread fruit (Artocarpus altilis), prawns, cuttle fish, tuna, and canned fish were implicated.
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      • Ratnayake R.M.U.
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      • Ranaweera K.K.D.S.
      Food allergy and anaphylaxis - 2063. Identification of foods causing hypersensitivity/allergy among school children in two sub-urban schools in Colombo District, Sri Lanka.
      However, confirmatory tests were not performed.
      Anaphylaxis is the most dangerous allergic manifestation. In a global review on food-based anaphylaxis,
      • Baseggio Conrado A.
      • Patel N.
      • Turner P.J.
      Global patterns in anaphylaxis due to specific foods: a systematic review.
      the commonest foods implicated were peanut, sesame, eggs, CM, celery, lupin, tree nuts, wheat, crustaceans, mollusks, fish, soy, and fruits. Other animal foods were also implicated. However, in Sri Lanka, CM (26%), eggs (2%), sesame (2%), spices other than sesame (2%), wheat (3%), crustaceans (4%), mollusks (1%), and fish (2%) were responsible for anaphylaxis.
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      • Dasanayake W.M.D.K.
      • Karunatilake C.
      • Wickramasingha G.D.
      • De Silva B.D.
      • Malavige G.N.
      Aetiology of anaphylaxis in patients referred to an immunology clinic in Colombo, Sri Lanka.
      Anaphylaxis to red meats were seen in 40% of patients in Sri Lanka, much more than in other countries.
      Two novel food allergies have been identified in the past 2 decades, both leading to anaphylaxis. Food-dependent exercise-induced anaphylaxis (FDEIA) occurs when physical exertion follows ingestion of the implicated food, generally within 4 hours. While many foods have been implicated, wheat is responsible for FDEIA in Sri Lanka.
      • de Silva N.R.
      • Dasanayake W.M.D.K.
      • Karunatilleke C.
      • Malavige G.N.
      Food dependant exercise induced anaphylaxis a retrospective study from 2 allergy clinics in Colombo, Sri Lanka.
      Alpha gal allergy is responsible for allergy to red meats. A tick bite sensitizes a patient to a carbohydrate moiety (alpha gal), which is present in the saliva of ticks and in non-primate mammals.
      • Wilson J.M.
      • Platts-Mills T.A.E.
      Red meat allergy in children and adults.
      Ingestion of red meat leads to delayed anaphylaxis (up to 7 hours after ingestion). While this condition has not been reported so far in Sri Lanka, we have identified a number of such persons.
      The present study aims to evaluate the foods that cause immediate type hypersensitivity, and to compare with data from Asia and the west.

      Methods

      Our immunology clinic in Sri Lanka caters to patients from the entire country. Patients with allergy are investigated and treated in the clinic. In this retrospective study, the clinic records from 2010–January 2022, a period of 12 years, were evaluated for probable allergy. Patients who had clinical features suggestive of immediate hypersensitivity, reproducibility between specific food ingestion and symptom(s) occurrence, and confirmation of the relevant food by detection of food allergen-specific IgE, were selected. Patients who did not participate in testing, and those with food allergy leading to asthma or atopic dermatitis, and where a food allergen could not be identified, were excluded. The diagnosis of anaphylaxis was based on the clinical history and examination findings as noted in the diagnosis card or bed head ticket. The diagnostic criteria included one of 3 clinical scenarios; namely, (1) acute onset of skin manifestations associated with respiratory or cardiovascular signs or symptoms, (2) involvement of at least 2 systems (skin, respiratory, cardiovascular, or gastrointestinal) that occurred rapidly after exposure to a likely allergen for that patient, or (3) reduced blood pressure after exposure to a known allergen for that patient.
      • Muraro A.
      • Werfel T.
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      • et al.
      EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy.
      The diagnosis of food allergy was based on standard guidelines.
      • Muraro A.
      • Werfel T.
      • Hoffmann-Sommergruber K.
      • et al.
      EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy.
      Patients with a history of food allergy within 2 hours of ingestion were selected. The food allergy (FA) included oral allergy syndrome, acute urticaria/angioedema, rhino-conjunctivitis/asthma, gastrointestinal symptoms, anaphylaxis, and FDEIA. Confirmation of the specific food implicated was based on the history and the presence of IgE to the implicated food, by the presence of specific IgE (by Phadia ImmunoCap, using a Phadia 100), or by skin prick testing with commercial extracts (ALK Abello). In vitro allergens included the following; cow's milk, beef/pork, bovine gelatin, shrimp, cuttle fish, egg white and egg yolk, wheat, peanut, coconut, lentil, sesame seed, soy bean, tuna, salmon, mackerel, yeast, and tomato. Skin prick reagents included cow's milk, beef/pork/mutton, egg (whole/white/yolk), coconut, lentils, almond, brazil, cashew and hazel nuts, shrimp, cuttle-fish, pineapple, banana, and melon. Where commercial extracts or in vitro diagnostics were not available, as for example, fruits and vegetables, prick to prick testing was performed. Component resolved diagnostics (CRD) were performed with reagents from Phadia ImmunoCap.
      • Matricardi P.M.
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      • Hoffmann H.J.
      • et al.
      EAACI molecular allergology user's guide.
      These include rTri a 19 omega-5 gliadin, nGal d 1 ovomucoid, nGal d 2 ovalbumin, nBos d 4 alpha-lactalbumin, nBos d 5 beta-lactoglobulin, nBos d 8 casein, nBos d 6 BSA, and nGal-alpha-1,3-Gal (alpha-Gal).
      Alpha-gal allergy was diagnosed when there was a delayed onset of symptoms of up to 6 hours after ingestion of red meat with or without a history of tick bite.
      • Wilson J.M.
      • Platts-Mills T.A.E.
      Red meat allergy in children and adults.
      Diagnosis was confirmed if IgE to alpha gal >0.35 kUA/L, IgE to alpha-gal > IgE to beef/pork,
      • Wilson J.M.
      • Schuyler A.J.
      • Workman L.
      • et al.
      Investigation into the α-gal syndrome: characteristics of 261 children and adults reporting red meat allergy.
      and IgE to bovine serum albumin (Bos d 6) was negative.
      • Wilson J.M.
      • Platts-Mills T.A.E.
      Red meat allergy in children and adults.
      Primary red meat allergy was diagnosed where symptoms appeared within 2 hours of ingestion, and IgE to beef/pork or skin prick testing with commercial extracts were positive. Patients with positive results were analyzed with component resolved diagnostics, including IgE to Bos d 6 (bovine serum albumin, BSA) and bovine gelatin.
      FDEIA was identified when symptoms and signs of allergy, including anaphylaxis, occurred during or within an hour of exercise, preceded by ingestion of food (for up to 4 hours), or by ingestion immediately after exertion.
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      Food-dependent, exercise-induced anaphylaxis: diagnosis and management in the outpatient setting.
      People who developed allergy to the food in the absence of exertion, or with exercise unaccompanied by ingestion of the food, were excluded. The diagnosis was confirmed by testing for IgE to the culprit food. IgE to omega 5 gliadin was done in patients where the implicated food was wheat. Due to safety issues, challenge testing was not done.
      • Feldweg A.M.
      Food-dependent, exercise-induced anaphylaxis: diagnosis and management in the outpatient setting.

      Results

      A total of 1255 patients attending the allergy clinic were evaluated for possible food allergy (FA), of whom 346 (27.5%) patients were diagnosed with immediate FA (Table 1). Seventy-three (21.09%) had allergy to multiple foods. Cow's milk allergy (CMA) was the commonest allergen diagnosed in 31.2% of patients followed by red meat allergy (27.7%) and FDEIA in 17.9%. Galactose-alpha-1,3-galactose (alpha-gal) allergy, and allergy to crustaceans, egg, gelatin, wheat, coconut milk, and mollusks were seen in 2–10% of patients. Most other allergies were seen in <1% of patients. These include peanuts, jambu, pecan/walnut, spinach, horse purslane (sarana, Trianthema portulacastrum), moringa (Moringa oleifera), and jackfruit (Artocarpus heterophyllus).
      Table 1Patients’ ages at onset of different food allergies
      Food AllergenNumber of patients (n = 346)
      Some patients had reacted to more than one food allergen.
      Age at onsetTotal (%)
      0–6 months6–12 months1–5 years5–12 years12–18 years>18 years
      Cow's Milk
      CM allergy was also present in 9.3% of patients with beef allergy and beef allergy was present in 15% of patients with CMA
      3829181328108 (31.2)
      Red meat
      CM allergy was also present in 9.3% of patients with beef allergy and beef allergy was present in 15% of patients with CMA
      05163393396 (27.7)
      Beef0392152361 (17.6)
      Pork0281771246 (13.3)
      Mutton02332414 (4)
      Venision0022004 (1.2)
      Others (Camel, Rabbit, Wild boar)0003003 (0.9)
      FDEIA01020132862 (17.9)
      Alpha- Gal008112829 (8.4)
      Crustaceans004351123 (6.6)
      Prawns004231019 (5.5)
      Crabs0001146 (1.7)
      Shrimp0000123 (0.9)
      Egg015210018 (5.2)
      Gelatin01532213 (3.8)
      Wheat01111610 (2.9)
      Coconut14500010 (2.9)
      Mollusks0011147 (2)
      Cuttlefish0011147 (2)
      Fish0000033 (0.9)
      Sesame0020013 (0.9)
      Other foods (Peanuts, jambu, soy, lentils/legumes mushroom, pecan/walnut, banana, mango, spinach, horse purslane/ sarana (Trianthema portulacastrum), moringa (Moringa oleifera), jackfruit (Artocarpus heterophyllus), tomato)02620717 (4.9)
      a Some patients had reacted to more than one food allergen.
      b CM allergy was also present in 9.3% of patients with beef allergy and beef allergy was present in 15% of patients with CMA
      The onset of CMA was mainly in childhood. However, the onset of CMA in 10/108 patients (9.2%) was at 12 years or later, 8 patients developing symptoms after 18 years. Thirty-three patients with CMA had red meat allergy (30.6%). Of the 67 patients with CMA in infancy, only 6 had red meat allergy, which developed after CMA, whereas of the 23 patients who developed CMA after 5 years, 16 had red meat allergy, of whom 14/23 (60.9%) developed CMA after read meat allergy (Table 2).
      Table 2Red meat allergy in patients with cow's milk allergy (CMA)
      AgeOnset of CMA (n = 108)Red meat allergyOnset of red meat allergy before CMAOnset of red meat allergy after CMA
      0–6 months38202
      6–12 months29404
      1–5 years181046
      5–12 years13972
      12–18 years2110
      >18 years8660
      One hundred and twenty-five patients had allergy to red meats, of whom 96 (76.8%) were considered as having primary red meat allergy. The onset in the majority of patients with primary red meat allergy was in childhood. However, in 33/96 (34.3%), it was in adulthood (>18 years) (Table 1). Thirty-three patients with primary beef allergy (33.3%) had CMA.
      Patients with a delayed onset (2–6 hours) were diagnosed with alpha-gal syndrome. Most patients with alpha-gal allergy (21/29, 72.4%) had initial symptoms in childhood and adolescence. Eight of 29 (27.5%) patients gave a history of tick bite within the previous year; however, the identity of the tick is not known.
      Almost half of patients (11/23, 47.8%) allergic to crustaceans had initial symptoms in adulthood.
      Anaphylaxis was diagnosed in 213 patients (Table 3). FDEIA is the commonest cause detected in 24.7% of patients and wheat was the only food implicated. Menstruation, taking non-steroidal anti-inflammatory drugs and inhalation of cannabis were cofactors in one patient each. The other major causes of anaphylaxis were primary red meat allergy (23%), CMA (21.5%), and alpha-gal allergy (10.3%).
      Table 3Patients’ ages at onset of anaphylaxis to different food
      Cause of anaphylaxisNumber of patients with anaphylaxis (n = 213)
      Some patients had anaphylaxis to more than one food allergen.
      Age at onsetTotal
      0–6 months6–12 months1–5 years5–12 years12–18 years>18 years
      FDEIA
      Food Dependent Exercise Induced Anaphylaxis
      00019112757 (26.7)
      Red meat0182141549 (23.0)
      Beef0041421030 (14.0)
      Pork00583723 (10.7)
      Mutton0121116 (2.8)
      Venison0010001 (0.4)
      Others (camel, rabbit, wild boar)0002002 (0.9)
      Cow's Milk1591072346 (21.5)
      Alpha- Gal00591722 (10.3)
      Crustaceans0001269 (3.9)
      Prawns0001168 (3.7)
      Crabs0001113 (1.4)
      Shrimp0000123 (1.4)
      Gelatin0033107 (3.2)
      Coconut1420007 (3.2)
      Wheat0110046 (2.8)
      Mollusks0000044 (1.7)
      Cuttlefish0000044 (1.7)
      Egg0300003 (1.4)
      Fish0000033 (1.4)
      Other foods01410814 (6.6)
      TOTAL161933612177213
      a Some patients had anaphylaxis to more than one food allergen.
      b Food Dependent Exercise Induced Anaphylaxis
      In adults the commonest cause of anaphylaxis was FDEIA (47.3%), followed by primary red meat (30.6%) and alpha–gal (31.8%) (Table 3). Anaphylaxis to crustaceans, wheat, and fish were also seen.
      CM was the commonest cause of anaphylaxis in infancy (68.5%) followed by coconut milk (14.2%) and eggs (8.5%). CM was also the commonest cause (30.3%) in children aged 1–5 years followed by red meats (24.2%) and alpha-gal (15.1%) Primary red meat allergy was the commonest cause of anaphylaxis from 5 to 12 years (34.4%) along with FDEIA (31.1%). FDEIA was the commonest cause from 12 to 18 years (52.3%).
      Patients with red meat allergy and/or CMA developed allergy, including anaphylaxis, to vaccines containing bovine/porcine products (Table 4).
      Table 4Patients with allergy to both food (red meat, cow's milk, gelatin) and vaccines
      VaccineFood AllergyTotal (n = 40)
      Red meatCow's milkRed meat + Cow's milkCow's milk + Gelatin
      MMR
      Measles, Mumps and Rubella.
      495119
      MR
      Measles-Rubella.
      00101
      Measles10203
      Rubella00224
      JE
      Japanese Encephalitis.
      11406
      aTd
      Adult Tetanus diptheria
      00112
      DT
      Diptheria Tetanus.
      02114
      ARV
      Anti-Rabies Vaccine
      10001
      a Measles, Mumps and Rubella.
      b Measles-Rubella.
      c Japanese Encephalitis.
      d Adult Tetanus diptheria
      e Diptheria Tetanus.
      f Anti-Rabies Vaccine
      Rare causes included anaphylaxis due to ingestion of horse purslane (Trianthema portulacastrum), locally known as "Sarana", identified in 1 patient. In addition, anaphylaxis was rarely seen with to sesame peanuts, lentils, soy, jambu, banana, mango, spinach, moringa, jackfruit, and tomato.

      Discussion

      The pattern of food allergy depends on the feeding patterns of each country.
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      However, the pattern of food allergy seen in our study has important differences with other Asian countries as well as with Europe and the United States (Table 5).
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      • Lee B.W.
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      Immediate food hypersensitivity among adults attending a clinical immunology/allergy centre in Singapore.
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      A cross-sectional, population-based study on the prevalence of food allergies among children in two different socio-economic regions of Vietnam.
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      Table 5Comparison of food allergy in Sri Lanka with countries in Asia, Europe and USA
      The foods are displaced in descending order of prevalence
      Sri LankaThailandKoreaChinaHong Kong
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      • Ogorodova L.M.
      • Mahesh P.A.
      • et al.
      Comparative study of food allergies in children from China, India, and Russia: the EuroPrevall-INCO surveys.
      Taiwan
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      • Huang C.F.
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      SingaporeJapan
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      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology; Japanese society of allergology. Japanese guidelines for food allergy 2020.
      VietnamIndiaUSEurope
      <1 year CM,Hen's egg<1 years
      • Sripramong C.
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      • Srisuwatchari W.
      • Pacharn P.
      • Jirapongsananuruk O.
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      Food sensitization and food allergy in allergic Thai patients from a tertiary care center in Thailand.
      Hen's egg CM,Soya
      0–2 years
      • Lee S.
      A Study for Prevention and Control of Food allergy. Research 104 Report of Grant from Korea Ministry of Food and Drug Safety (MFDS) in 2015.
      CM,Hen's egg
      0–2 year
      • Sha L.
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      • Wu Y.
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      A cross-sectional study of the prevalence of food allergies among children younger than ages 14 years in a Beijing urban region.
      Seafood,Fruits CM,Hen”s egg
      1 year
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      Hen's egg CM
      <1yearHen's egg CMWheat<15 years
      • Dey D.
      • Ghosh N.
      • Pandey N.
      • Gupta Bhattacharya S.
      A hospital-based survey on food allergy in the population of Kolkata, India.
      BananaEggBrinjalWheatLady's finger CM
      0–5 years
      • Dey D.
      • Ghosh N.
      • Pandey N.
      • Gupta Bhattacharya S.
      A hospital-based survey on food allergy in the population of Kolkata, India.
      CMPeanutHen's egg
      1–5 years CM,Red meat,Alpha gal,Gelatin,Coconut,Crustaceans0–6 years
      • Park M.
      • Kim D.
      • Ahn K.
      • Kim J.
      • Han Y.
      Prevalence of immediate- type food allergy in early childhood in Seoul.
      Hen's egg,Peanut,Soya,Fruits,Tree nuts,Crustaceans
      0–7 years
      • Zeng G.Q.
      • Luo J.Y.
      • Huang H.M.
      • et al.
      Food allergy and related risk factors in 2540 preschool children: an epidemiological survey in Guangdong Province, southern China.
      Shrimp,Crabs,Mango, CM,Hen's egg
      18 months
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      Hen's eggShellfish24 months
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      Hen's egg36 months
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      ShellfishHen's egg48 months
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      ShellfishHen's egg
      1 yearHen's eggFish roe CMPeanutsFruits
      611 yearsShrimpFish/Hen's egg/crabs3 yearsShrimpFishCrabs23 yearsFish roeHen's eggPeanutTree nutFruitsHue26 years
      • Le T.T.K.
      • Nguyen D.H.
      • Vu A.T.L.
      • Ruethers T.
      • Taki A.C.
      • Lopata A.L.
      A cross-sectional, population-based study on the prevalence of food allergies among children in two different socio-economic regions of Vietnam.
      Tien Giang26 years
      • Le T.T.K.
      • Nguyen D.H.
      • Vu A.T.L.
      • Ruethers T.
      • Taki A.C.
      • Lopata A.L.
      A cross-sectional, population-based study on the prevalence of food allergies among children in two different socio-economic regions of Vietnam.
      610 years
      • Grabenhenrich L.
      • Trendelenburg V.
      • Bellach J.
      • et al.
      Frequency of food allergy in school-aged children in eight European countries-The EuroPrevall-iFAAM birth cohort.
      Iceland, UK, Germany, Spain, Poland-CMHen's eggPeanutThe Netherlands- CMHen's eggGreece-CM
       ShrimpFishHen's eggMollusksCM ShrimpBeefMollusksFish
      37 years
      • Rangkakulnuwat P.
      • Lao-Araya M.
      The prevalence and temporal trends of foodallergy among preschool children in NorthernThailand between 2010 and 2019.
      CM,Hen's eggs,Shrimp
      36 years
      • Lee S.
      A Study for Prevention and Control of Food allergy. Research 104 Report of Grant from Korea Ministry of Food and Drug Safety (MFDS) in 2015.
      Walnut,Hen's egg,CM
      35 years
      • Sha L.
      • Shao M.
      • Liu C.
      • Wu Y.
      • Chen Y.
      A cross-sectional study of the prevalence of food allergies among children younger than ages 14 years in a Beijing urban region.
      Fruits,Seafood
      418 yearsShrimpCrabsFishMangoMollusksCMPeanutHen's egg46 yearsFruitsHen's eggPeanutBuckwheat/fish roe611 years
      • Li J.
      • Ogorodova L.M.
      • Mahesh P.A.
      • et al.
      Comparative study of food allergies in children from China, India, and Russia: the EuroPrevall-INCO surveys.
      Very low prevalence of FA
      610 years
      • Gupta R.S.
      • Warren C.M.
      • Smith B.M.
      • et al.
      The public health impact of parent-reported childhood food allergies in the United States.
      PeanutsCM
      710 years
      • Lyons S.A.
      • Clausen M.
      • Knulst A.C.
      • et al.
      Prevalence of food sensitization and food allergy in children across Europe.
      Poland, The Netherlands,Spain, Iceland, Lithuania, Greece, SwitzerlandHazelnutPeanutApplePeachKiwiCarrotSpain, Iceland ShrimpFishGreeceFish
      512 yearsRed meatFDEIA (wheat)CMAlpha gal614 years
      • Lee S.C.
      • Kim S.R.
      • Park K.H.
      • Lee J.H.
      • Park J.W.
      Clinical features and culprit food allergens of Korean adult food allergy patients: a cross-sectional single-institute study.
      Fruits,Seafood6 – 11
      • Li J.
      • Ogorodova L.M.
      • Mahesh P.A.
      • et al.
      Comparative study of food allergies in children from China, India, and Russia: the EuroPrevall-INCO surveys.
      yearsShrimp,
      719 yearsCrustaceansFruitsHen's egg/wheatBuckwheat1113 years
      • Gupta R.S.
      • Warren C.M.
      • Smith B.M.
      • et al.
      The public health impact of parent-reported childhood food allergies in the United States.
      PeanutsCMShellfish
      1218 yearsRed meatFDEIA (wheat)CMAlpha gal
      >18 yearsRed meatFDEIA (wheat)CrustaceansAdults
      • Lee S.C.
      • Kim S.R.
      • Park K.H.
      • Lee J.H.
      • Park J.W.
      Clinical features and culprit food allergens of Korean adult food allergy patients: a cross-sectional single-institute study.
      Pollen food allergy syndrome CrustaceansWheatBuckwheat Peanut Walnut Alpha Gal
      >18yearsCM/ShrimpCrabsMollusksMangoPeanutAdults
      • Thong B.Y.
      • Cheng Y.K.
      • Leong K.P.
      • Tang C.Y.
      • Chng H.H.
      Immediate food hypersensitivity among adults attending a clinical immunology/allergy centre in Singapore.
      ShrimpCrabsMolluscs
      >20 yearsWheatFishCrustaceansFruits1650 years
      • Le T.T.K.
      • Tran T.T.B.
      • Ho H.T.M.
      • Vu A.T.L.
      • McBryde E.
      • Lopata A.L.
      The predominance of seafood allergy in Vietnamese adults: results from the first population-based questionnaire survey.
      CrustaceansFishMollusksBeefEggCM
      1540 years
      • Dey D.
      • Ghosh N.
      • Pandey N.
      • Gupta Bhattacharya S.
      A hospital-based survey on food allergy in the population of Kolkata, India.
      BananaBrinjalLady's figureTomatoWheat
      Adults
      • Gupta R.S.
      • Warren C.M.
      • Smith B.M.
      • et al.
      Prevalence and severity of food allergies among US adults.
      Shellfish, CMPeanutsTree nutsFinfish
      2054 years
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      CMApple
      >40 years
      • Matricardi P.M.
      • Kleine-Tebbe J.
      • Hoffmann H.J.
      • et al.
      EAACI molecular allergology user's guide.
      BananaBrinjalHen's eggTomato
      Adults
      • Lyons S.A.
      • Burney P.G.J.
      • Ballmer-Weber B.K.
      • et al.
      Food allergy in adults: substantial variation in prevalence and causative foods across Europe.
      Switzerland, Poland, The NetherlandsHazelnutApplePeachSpainPeachMelonShrimp
      a The foods are displaced in descending order of prevalence
      Cow's milk allergy (CMA) was the commonest food allergy in childhood in our population. CMA is one of the commonest food allergies among young children throughout Asia
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      ,
      • Sripramong C.
      • Visitsunthorn K.
      • Srisuwatchari W.
      • Pacharn P.
      • Jirapongsananuruk O.
      • Visitsunthorn N.
      Food sensitization and food allergy in allergic Thai patients from a tertiary care center in Thailand.
      ,
      • Lee S.
      A Study for Prevention and Control of Food allergy. Research 104 Report of Grant from Korea Ministry of Food and Drug Safety (MFDS) in 2015.
      ,
      • Sha L.
      • Shao M.
      • Liu C.
      • Wu Y.
      • Chen Y.
      A cross-sectional study of the prevalence of food allergies among children younger than ages 14 years in a Beijing urban region.
      ,
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology; Japanese society of allergology. Japanese guidelines for food allergy 2020.
      and high levels are also seen in Europe and United States.
      • Burks A Wesley
      • Holgate Stephen T.
      • O'Hehir Robyn E.
      • et al.
      Middleton's Allergy 2-Volume Set.
      ,
      • Gupta R.S.
      • Warren C.M.
      • Smith B.M.
      • et al.
      The public health impact of parent-reported childhood food allergies in the United States.
      ,
      • Grabenhenrich L.
      • Trendelenburg V.
      • Bellach J.
      • et al.
      Frequency of food allergy in school-aged children in eight European countries-The EuroPrevall-iFAAM birth cohort.
      A substantial proportion of our patients had an onset after 5 years, and in adulthood. These patients had developed red meat allergy before onset of CMA (Table 2) which may have predisposed to subsequent development of CMA. BSA may be responsible for the cross-reactivity.
      • Martelli A.
      • De Chiara A.
      • Corvo M.
      • Restani P.
      • Fiocchi A.
      Beef allergy in children with cow's milk allergy; cow's milk allergy in children with beef allergy.
      Convincing data have emerged that CMA may manifest in adult life,
      • Warren C.M.
      • Agrawal A.
      • Gandhi D.
      • Gupta R.S.
      The US population-level burden of cow's milk allergy.
      and further studies on the underlying mechanisms are warranted.
      • Flom J.D.
      • Sicherer S.H.
      Epidemiology of cow's milk allergy.
      Allergy to red meats come in 3 different forms; primary red meat allergy, alpha-gal allergy, and pork cat syndrome. Only primary red meat and alpha-gal allergy were identified among our patients. Primary red meat allergy is the second most common food allergy in our patients. This is unusual, as, due to cultural and religious reasons, consumption of red meat is low. Red meat allergy, while uncommon, is identified mainly in children in other countries,
      • Wilson J.M.
      • Platts-Mills T.A.E.
      Red meat allergy in children and adults.
      whereas in 34.3% of our patients, the onset was in those over 18 years.
      Twenty-nine patients were diagnosed with alpha-gal allergy. In a previous paper from our group, alpha -gal allergy was not detected.
      • de Silva N.R.
      • Dasanayake W.M.D.K.
      • Karunatilake C.
      • Wickramasingha G.D.
      • De Silva B.D.
      • Malavige G.N.
      Aetiology of anaphylaxis in patients referred to an immunology clinic in Colombo, Sri Lanka.
      To our knowledge, these are the first reported cases from the Indian subcontinent. None of the patients with immediate reactions (within 2 hours) to red meat were tested for IgE to alpha-gal due to financial constraints. Some of these patients may have had alpha-gal allergy. This is a limitation in our study.
      Egg allergy was relatively uncommon in our patients, after infancy, unlike in Asia,
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      Europe, and United States.
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      For example, egg allergy predominates over CMA among children below 5 years in Korea,
      • Park M.
      • Kim D.
      • Ahn K.
      • Kim J.
      • Han Y.
      Prevalence of immediate- type food allergy in early childhood in Seoul.
      Singapore,
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      and Japan.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology; Japanese society of allergology. Japanese guidelines for food allergy 2020.
      However, the prevalence of egg allergy in Asia is lower than in the developed west.
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      Shellfish allergy was seen in 6.6% of patients, unlike in studies from India, where crustacean allergy was not seen.
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      ,
      • Dey D.
      • Ghosh N.
      • Pandey N.
      • Gupta Bhattacharya S.
      A hospital-based survey on food allergy in the population of Kolkata, India.
      ,
      • Grabenhenrich L.
      • Trendelenburg V.
      • Bellach J.
      • et al.
      Frequency of food allergy in school-aged children in eight European countries-The EuroPrevall-iFAAM birth cohort.
      Among Chinese children there is a high prevalence of crustacean allergy
      • Sha L.
      • Shao M.
      • Liu C.
      • Wu Y.
      • Chen Y.
      A cross-sectional study of the prevalence of food allergies among children younger than ages 14 years in a Beijing urban region.
      ,
      • Zeng G.Q.
      • Luo J.Y.
      • Huang H.M.
      • et al.
      Food allergy and related risk factors in 2540 preschool children: an epidemiological survey in Guangdong Province, southern China.
      and it is the leading cause of food allergy among younger children in some south East Asian countries such as Vietnam,
      • Le T.T.K.
      • Nguyen D.H.
      • Vu A.T.L.
      • Ruethers T.
      • Taki A.C.
      • Lopata A.L.
      A cross-sectional, population-based study on the prevalence of food allergies among children in two different socio-economic regions of Vietnam.
      Taiwan,
      • Wu T.C.
      • Tsai T.C.
      • Huang C.F.
      • et al.
      Prevalence of food allergy in Taiwan: a questionnaire-based survey.
      and Hong Kong,
      • Li J.
      • Ogorodova L.M.
      • Mahesh P.A.
      • et al.
      Comparative study of food allergies in children from China, India, and Russia: the EuroPrevall-INCO surveys.
      but is less common in Japan
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology; Japanese society of allergology. Japanese guidelines for food allergy 2020.
      and South Korea.
      • Lee S.
      A Study for Prevention and Control of Food allergy. Research 104 Report of Grant from Korea Ministry of Food and Drug Safety (MFDS) in 2015.
      It is seen in older children and adults in Japan
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology; Japanese society of allergology. Japanese guidelines for food allergy 2020.
      and Vietnam
      • Le T.T.K.
      • Tran T.T.B.
      • Ho H.T.M.
      • Vu A.T.L.
      • McBryde E.
      • Lopata A.L.
      The predominance of seafood allergy in Vietnamese adults: results from the first population-based questionnaire survey.
      and is the commonest adult food allergy in Singapore.
      • Thong B.Y.
      • Cheng Y.K.
      • Leong K.P.
      • Tang C.Y.
      • Chng H.H.
      Immediate food hypersensitivity among adults attending a clinical immunology/allergy centre in Singapore.
      Crustacean allergy is less common in Europe and United States.
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      ,
      • Grabenhenrich L.
      • Trendelenburg V.
      • Bellach J.
      • et al.
      Frequency of food allergy in school-aged children in eight European countries-The EuroPrevall-iFAAM birth cohort.
      • Lyons S.A.
      • Clausen M.
      • Knulst A.C.
      • et al.
      Prevalence of food sensitization and food allergy in children across Europe.
      • Lyons S.A.
      • Burney P.G.J.
      • Ballmer-Weber B.K.
      • et al.
      Food allergy in adults: substantial variation in prevalence and causative foods across Europe.
      The early introduction of shellfish and consumption of raw food have been considered as causes for this phenomenon.
      • Cyy Wai
      • Leung N.Y.H.
      • Leung A.S.Y.
      • Wong G.W.K.
      • Leung T.F.
      Seafood allergy in Asia: geographical specificity and beyond.
      Shellfish is not consumed raw, and is not a food that is introduced early in Sri Lanka. Another possibility is cross reactivity to house dust mites (HDM) and cockroaches, in tropical climes with high humidity.
      • Cyy Wai
      • Leung N.Y.H.
      • Leung A.S.Y.
      • Wong G.W.K.
      • Leung T.F.
      Seafood allergy in Asia: geographical specificity and beyond.
      ,
      • Tham E.H.
      • Leung D.Y.M.
      How different parts of the world provide new insights into food allergy.
      However, data from India, with similar levels of humidity and exposure to HDM, reveal that, while sensitization to shrimp is high, there was no clinical allergy
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      ,
      • Dey D.
      • Ghosh N.
      • Pandey N.
      • Gupta Bhattacharya S.
      A hospital-based survey on food allergy in the population of Kolkata, India.
      ,
      • Grabenhenrich L.
      • Trendelenburg V.
      • Bellach J.
      • et al.
      Frequency of food allergy in school-aged children in eight European countries-The EuroPrevall-iFAAM birth cohort.
      Peanut allergy was not seen in children born in Sri Lanka. The prevalence of peanut allergy is 1–2% in the west, but uncommon in Asia and other areas,
      • Lieberman J.A.
      • Gupta R.S.
      • Knibb R.C.
      • et al.
      The global burden of illness of peanut allergy: a comprehensive literature review.
      including India and China.
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      Two children, born in Europe but residing in Sri Lanka after infancy had peanut allergy. Asian children born in Australia had higher peanut allergy, compared to children from the same ethnic group born in their native country but who had subsequently migrated to Australia.
      • Panjari M.
      • Koplin J.J.
      • Dharmage S.C.
      • et al.
      Nut allergy prevalence and differences between Asian-born children and Australian-born children of Asian descent: a state-wide survey of children at primary school entry in Victoria, Australia.
      Early introduction of peanuts reduces the risk of peanut allergy.
      • Du Toit G.
      • Roberts G.
      • Sayre P.H.
      • et al.
      Randomized trial of peanut consumption in infants at risk for peanut allergy.
      Introduction of peanuts at 6–12 months is recommended in Sri Lanka, which may explain the low incidence of peanut allergy in our study population.
      • Jayatissa R.
      • Gunathilaka M.
      • Gankanda W.
      • Uduwaka C.
      • Hewawitharana K.
      Locally Available Improved Recipes for Complementary Feeding and Case Histories.
      Fish allergy is rare in Sri Lanka similar to India, where clinical allergy was not detected.
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.
      Fish allergies are relatively uncommon in South East Asian countries, even though there are regional differences.
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      Philippines has a relatively high rate of fish allergy
      • Connett G.J.
      • Gerez I.
      • Cabrera-Morales E.A.
      • et al.
      A population-based study of fish allergy in the Philippines, Singapore and Thailand.
      Primary wheat allergy is less common in our population compared to Japan,
      • Tham E.H.
      • Lee B.W.
      • Chan Y.H.
      • et al.
      Low food allergy prevalence despite delayed introduction of allergenic foods-data from the GUSTO cohort.
      Korea,
      • Lee S.C.
      • Kim S.R.
      • Park K.H.
      • Lee J.H.
      • Park J.W.
      Clinical features and culprit food allergens of Korean adult food allergy patients: a cross-sectional single-institute study.
      and United States,
      • Fleischer D.M.
      • Perry T.T.
      • Atkins D.
      • et al.
      Allergic reactions to foods in preschool-aged children in a prospective observational food allergy study.
      but commoner than in India and other Asian countries.
      • Hossny E.
      • Ebisawa M.
      • El-Gamal Y.
      • et al.
      Challenges of managing food allergy in the developing world.
      Sensitization to wheat was common in adults in the Indian study, but symptomatic wheat allergy was rare.
      • Mahesh P.A.
      • Wong G.W.
      • Ogorodova L.
      • et al.
      Prevalence of food sensitization and probable food allergy among adults in India: the EuroPrevall INCO study.

      Anaphylaxis

      A majority of patients in our cohort had anaphylaxis, the probable reason being minor allergies not being referred to our unit for further investigation.
      FDEIA was common in our cohort from 5 years of age, and was the commonest cause after 12 years. The reason for the high prevalence is possibly because many clinicians were unaware of the condition and referred such patients to our clinic. Wheat was the only food identified. While wheat is the commonest allergen, other foods are also implicated elsewhere.
      • de Silva N.R.
      • Dasanayake W.M.D.K.
      • Karunatilleke C.
      • Malavige G.N.
      Food dependant exercise induced anaphylaxis a retrospective study from 2 allergy clinics in Colombo, Sri Lanka.
      Red meat was the commonest allergen in the 5–12-year age group, and was the second most common in adults. In addition, patients with red meat allergy developed allergic reactions including anaphylaxis, to vaccines containing bovine/porcine components such as the measles, mumps, and rubella (MMR) and the live Japanese encephalitis (JE) vaccine. Allergy to bovine/porcine excipients have been implicated in allergic reactions to these vaccines.
      • Piñones M.
      • Landaeta M.
      • Bustos P.
      • et al.
      Hypersensitivity reactions to measles-mumps-rubella vaccine in patients with IgE-mediated cow's milk allergy.
      Patients with CMA
      • Piñones M.
      • Landaeta M.
      • Bustos P.
      • et al.
      Hypersensitivity reactions to measles-mumps-rubella vaccine in patients with IgE-mediated cow's milk allergy.
      or red meat allergy
      • de Silva R.
      • Dasanayake W.M.D.K.
      • Wickramasinhe G.D.
      • et al.
      Sensitization to bovine serum albumin as a possible cause of allergic reactions to vaccines.
      may be at risk and therefore caution should be exercised when administering such vaccines. Gelatin or BSA
      • de Silva R.
      • Dasanayake W.M.D.K.
      • Wickramasinhe G.D.
      • et al.
      Sensitization to bovine serum albumin as a possible cause of allergic reactions to vaccines.
      has been implicated as the culprit allergen. JE is a single dose vaccine, and most MMR reactions occurred with the second dose;
      • de Silva R.
      • Dasanayake W.M.D.K.
      • Wickramasinhe G.D.
      • et al.
      Sensitization to bovine serum albumin as a possible cause of allergic reactions to vaccines.
      the need for further vaccines did not arise in a majority of these patients. Unfortunately, vaccines free of bovine excipients are not available in Sri Lanka. Patients with alpha-gal allergy were not at risk of vaccine allergy, possibly due to its onset being after the age of immunization with these vaccines.
      Cow's milk was the most common cause of anaphylaxis in children below 5 years, as in other countries. Coconut was the second commonest cause of anaphylaxis in infancy. Coconut is part of the daily diet of a majority of Sri Lankans, and is a weaning food. Although data regarding coconut (Cocos nucifera) allergy is limited, a recent Australian paediatric case series reported 35 patients with allergy to coconut including 9 with anaphylaxis.
      • Pathmanandavel K.
      • Kaur N.
      • Joshi P.
      • Ford L.S.
      Anaphylaxis and allergy to coconut: an Australian pediatric case series.
      Anaphylaxis to hen's egg was uncommon, contrasting with data from Europe,
      • Grabenhenrich L.B.
      • Dölle S.
      • Moneret-Vautrin A.
      • et al.
      Anaphylaxis in children and adolescents: the European anaphylaxis registry.
      China, Japan, Korea, and Singapore.
      • Tham E.H.
      • Leung A.S.Y.
      • Pacharn P.
      • et al.
      APAPARI Anaphylaxis Study Group
      Anaphylaxis - lessons learnt when East meets west.
      Anaphylaxis to nuts and peanuts was uncommon similar to South Asia, but is relatively common in Hong Kong, Singapore, and in Europe and Australia.
      • Baseggio Conrado A.
      • Patel N.
      • Turner P.J.
      Global patterns in anaphylaxis due to specific foods: a systematic review.
      Anaphylaxis to fruits was also very rare in our population. This contrasts with the rest of the world, where it is common.
      • Baseggio Conrado A.
      • Patel N.
      • Turner P.J.
      Global patterns in anaphylaxis due to specific foods: a systematic review.
      Anaphylaxis due to ingestion of horse purslane (Trianthema portulacastrum), locally known as "Sarana", was identified in 1 patient. This has not been reported previously.

      Pollen food allergy syndrome

      No patient had pollen food allergy syndrome (PFAS). There are case reports of PFAS from India,
      • Bansal A.S.
      Aubergine and potato sensitivity with latex sensitisation and oral allergy syndrome.
      but they are rare compared to the west. The reason for this discrepancy is unclear.
      The present study was limited to patients referred from other centers for evaluation of food allergy. Some patients in whom the implicated food was easily identified may not have been referred to our unit, even though this may be a small number as our clinic is the only unit in the country offering diagnostic services, free of charge. In addition, we did not offer oral food challenges, which is the gold standard for food allergy diagnosis. However, the patients were included in the present study if they had clear evidence of allergy along with ingestion within 2 hours of onset of symptoms (except in FDEIA and alpha-gal allergy).
      • Wilson J.M.
      • Platts-Mills T.A.E.
      Red meat allergy in children and adults.

      Conclusions

      The main cause of food allergy in children was CM, whereas FDEIA and red meat allergy were common causes of food allergy/anaphylaxis in older children and adults. Red meat allergy was also implicated in allergic reactions to some childhood vaccines. Primary red meat allergy may be responsible for late onset CMA.

      Abbreviations

      CM; Cow's Milk, CMA; Cow's Milk Allergy, CRD; Component Resolved Diagnostics, FA; Food Allergy, FDEIA; Food Dependent Exercise Induced Anaphylaxis, HDM; House Dust Mites, IgE; Immunoglobulin E, LTP; Lipid Transfer Proteins, PFAS; Pollen Food Allergy Syndrome

      Declaration of competing interests

      The authors declare that they have no competing interests.

      Funding source

      Self-funded.

      Ethics statement

      Ethics approval was provided by the Ethics Review Committee, Medical Research Institute, Colombo 08, Sri Lanka (ERC approval No: 01/2022).
      The data were analyzed retrospectively and anonymized.

      Authors' contributions

      RDS, DD– conception, design of the work, acquisition, analysis, interpretation of data, drafted the work and substantively revised it.
      CK- acquisition.
      JI- acquisition, analysis.

      Consent for publication

      The authors have given their consent for the publication.

      Availability of data statement

      All (anonymized) data are available with the corresponding author.

      Acknowledgements

      Not applicable.

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