Food allergy affects approximately 2–4% of children and adults. This guideline provides recommendations for managing food allergy from the Global Allergy and Asthma European Network (GA2LEN). A multidisciplinary international Task Force developed the guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We reviewed the latest available evidence as of April 2021 (161 studies) and created recommendations by balancing benefits, harms, feasibility, and patient and clinician experiences. We suggest that people diagnosed with food allergy avoid triggering allergens (low certainty evidence). We suggest that infants with cow's milk allergy who need a breastmilk alternative use either hypoallergenic extensively hydrolyzed cow's milk formula or an amino acid-based formula (moderate certainty). For selected children with peanut allergy, we recommend oral immunotherapy (high certainty), though epicutaneous immunotherapy might be considered depending on individual preferences and availability (moderate certainty). We suggest considering oral immunotherapy for children with persistent severe hen's egg or cow's milk allergy (moderate certainty). There are significant gaps in evidence about safety and effectiveness of the various strategies. Research is needed to determine the best approaches to education, how to predict the risk of severe reactions, whether immunotherapy is cost-effective and whether biological therapies are effective alone or combined with allergen immunotherapy.
Bibliographical noteFunding Information:
Philippe Begin: personal fees: ALK, Aralez, Astra-Zeneca, Bausch health, DBV, Food Allergy Canada, Novartis, Pfizer, Sanofi, grants: Canadian Allergy and Immunology Foundation, Canadian Institutes of Health Research, DBV, Fonds de Recherches du Québec, Ministère de l’économie et de l'innovation du Québec, Novartis, Ontario Research Funds, Regeneron, Sanofi.
Hasan Arshad: grant: Food Standard Agency, Natasha Allergy Research Foundation.
Bertine Flokstra: employment: General Practitioners Research Institute (GPRI); GPRI has conducted investigator- and sponsor-initiated research funded by non-commercial organizations, academic institutes, and pharmaceutical companies (including AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Mundipharma, Novartis, and Teva).
Paul J Turner: personal fees: from Aimmune Therapeutics, DBV Technologies, Allergenis, UK Food Standards Agency; grants: National Institute for Health Research (NIHR)/Imperial Biomedical Research Centre, UK Medical Research Council, UK Food Standards Agency, End Allergies Together, Jon Moulton Charity Trust.
Antoine Deschildre: personal fees from Novartis, ALK, GSK, Sanofi, Aimmune Therapeutics, DBV Technologies, Nestlé Health Science, Boehringer Ingelheim, Stallergenes Greer, DBV Technologies, Nutricia. Grant from Fondation du Souffle, Conseil Régional Hauts-de-France Research Program 2014–2018.
Elizabeth Angier: grant: Natasha Allergy Research Foundation; expert testimony UK Medicines and Healthcare Regulatory Authority; leadership BSACI, EAACI, WONCA.