How to Prepare for Your First Appointment With an Allergist if You Have a Possible Food Allergy

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Getting help

It can take a long time before food allergy symptoms are recognised for what they are; sometimes they are so sporadic that they don’t seem to be caused by any one thing, sometimes they look like food poisoning, sometimes they are manageable with over-the-counter antihistamines and decongestants. However, if similar symptoms keep coming back, or if they are severe—especially if they involve breathing problems—or if the medications you have been taking stop working, you should consider seeking treatment.

Your first port of call will probably be your GP / family doctor. They will probably ask you to describe your symptoms so that they can determine whether or not you may have an allergy or whether your symptoms could be explained by something else. This may or may not be followed by a physical examination (to look for visible signs of reactions). On the off-chance you have had obvious reactions in the past, you might want to take some photos so you have something to show them.

In some cases, GPs can diagnose and treat allergies; hay fever for example, often has common and recognisable symptoms that will respond to routine medication and certain practical precautions. However, a food allergy is often more difficult to diagnose; the range of possible symptoms is wide and varied and it can be difficult to identify the culpable food. You may also have more than one trigger.

Although the average GP is not qualified to carry out a skin prick test, they can order some blood tests if they suspect a certain food allergen. But blood test results are often not straightforward and they still need to be interpreted by a specialist. So, if your doctor suspects a foodallergy to a trigger that they cannot identify, they should refer you to an allergist for further evaluation.

Questions, questions

During your first appointment, the allergist will ask you a detailed battery of questions. These questions—aka the medical/clinical history or, if you really want to be fancy about it, the anamnesis—are necessary to:

• Distinguish a food allergy from a raft of other food-related adverse reactions
• Distinguish between a classic IgE-mediated allergy and a non-IgE mediated reaction; this will affect the kind of tests that need to be carried out
• Identify a potential culprit food; a positive skin or blood test does not, in itself, determine a food allergy, but needs to be considered in combination with a history of reacting to that food
• Determine which steps to take next; which tests to take, which specialist (if any) to send you to, which medications to prescribe, what type of advice to give

The clearer and more detailed your answers, the more likely you are to get an accurate diagnosis and effective treatment.

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Questions about your symptoms

A good description of your symptoms is vital if the allergist is to assess the probability that you have an allergy and, if you undergo testing, to interpret the test results and identify your trigger food(s).

The allergist will want to know:

• When you began experiencing symptoms (how long ago)
• What (and how severe) those symptoms were
  • itching / tingling; where? (e.g. face, torso, arms)
  • redness, flushing; where?
  • skin rash; was it localised or generalised (all over the body)?
  • swelling; where (e.g. throat, tongue, face, eyes)? Was it substantial? Did you have difficulty swallowing or speaking?
  • coughing / sneezing
  • breathing difficulties / chest tightness / shallow breathing / wheezing / asthma
  • nausea / vomiting / diarrhoea / abdominal pain
  • fainting / light headedness / blurred vision / loss of consciousness / collapse
• Whether the symptoms resolved by themselves or whether you were given any medical treatment and, if so,
  • what were you given?
  • did it work?
  • how long did it take for the symptoms to resolve?
• How much time elapsed between you eating the food and the onset of the symptoms—this should help distinguish between a ‘classic’ IgE-mediated allergy and a delayed onset non-IgE mediated allergy. IgE-mediated reactions tend to happen between 15 and 120 minutes after eating/touching the allergen, the one known exception being an allergic reaction to red meat. Non-IgE mediated reactions tend to happen about 4 to 6 hours after the food is eaten, sometimes even longer
• How long the symptoms lasted—the average time to symptom resolution after a reaction is 4 to 12 hours
• Where you were when you experienced those symptoms, e.g.:
  • at home or at a friend/relative’s home, at school, in a restaurant (perhaps you were accidentally exposed to your trigger in a dish or pre-packaged food that you didn’t know contained it)
  • at the gym, out jogging (perhaps you react to food after exercise, you might have a version of food-dependant exercise-induced anaphylaxis, FDEIA)
• How often you’ve experienced these types of symptoms—if more than once, whether the symptoms are generally similar—i.e. consistent and reproducible— and/or whether they seem to be getting worse
• What, if anything, seems to improve your symptoms? e.g.:
  • taking over-the-counter medications like antihistamines
  • getting rid of the food by vomiting or going to the loo
  • buying another brand of the same food
  • being on holiday in another location
• Whether you ever experience periods of freedom from the symptoms—for example, if you never have a reaction during the winter, your allergy may be seasonal and linked to pollen exposure, or if you don’t experience the symptoms when on holiday, perhaps you have an occupational allergy
• Whether you have ever experienced similar symptoms at times other than after being exposed to a given food—perhaps it’s not a food allergy after all
• Whether you have experienced skin rashes on touching food or breathing problems on inhaling cooking vapours

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Questions about the suspected food allergen

You may already suspect a certain food (or foods) of causing your symptoms.

The allergist will want to know:

• Which food(s) you think you might be reacting to
• How much of that food you ate before having a reaction and whether you can ever eat that food without getting symptoms. This says something about the type of allergy (or intolerance) you may have, for example:
  • An IgE-mediated allergy is often triggered by a very small amount of allergen and will cause symptoms every time you eat it, although you need to reach a certain threshold amount before having a reaction. Alternatively, disorders like lactose intolerance generally require a person to eat or drink a relatively large amount before getting symptoms.
  • People with food-dependent exercise-induced anaphylaxis can eat their trigger food just fine without exercising, but they don’t necessarily require a lot of exercise to react to it; sometimes just crossing the road can be enough
• Whether you ate it cooked or raw—for instance, many people with egg allergy have a bad reaction to scrambled eggs but can they can eat baked eggs, or some people get a tingling tongue or mouth after eating a fresh apple but can eat apple sauce (these people may well have Pollen Food Syndrome)
• Whether you often eat that food—foods that you don’t normally eat are more likely to cause a bad allergic reaction than the ones you do normally eat
• Whether you regularly eat the suspect food with other foods—people often talk about the main dish or food they ate prior to a reaction, but they tend to forget sauces, dressings, sides or breads, which may actually be the cause of the reaction
• Whether there has been any possibility of cross-contamination—this is a real possibility when someone with known food allergies has a reaction to a meal of previously tolerated foods. This could happen when, for example, when cookware has not been thoroughly cleaned when preparing different meals at home, or when serving utensils are used for different dishes at a buffet, or when different foods are deep-fried in the same oil in restaurants or takeaways
• Whether the allergen could be ‘hidden’—this is an allergen that you don’t know about that is present in food you have not prepared yourself. For example,
  • You may have noticed that you always get a reaction when you eat a certain brand of waffle because, unlike other brands, this one contains lupin or soy flour which you are allergic to, or perhaps one brand uses vaguely termed ‘natural flavourings’ which are made using your food trigger
  • You may not have a reaction when you eat the chicken curry at your favourite Indian restaurant but when you tried making one at home that one time, you have a reaction because you used a blend of spices that contains an ingredient you are allergic to
  • You may have eaten a pre-packaged food that contains something you are allergic when on holiday abroad, because the major food allergens you are used to seeing on the label may not be legally required to be listed in that country
  • When it comes to precautionary ‘may contain’ labels, many people make the same mistakes and, for example, do not realise that those labels are voluntary, so just because a food does not display one does not mean that it could not be contaminated with their trigger food
  • When it comes to gluten, legislation does not require it to be mentioned when it is present under a certain amount
• Whether you have tried taking the food out of your diet and if so, was that helpful?

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Questions about possible contributing factors

Allergic reactions to foods often involve cofactors which are either necessary for the reaction to occur or make it worse.

The allergist will need to know:

• Whether you exercised 1 hour before or up to 6 hours after eating
• Whether you took any medications—especially nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin—just before or after eating
• Whether you drank any alcohol just before or after eating (alcohol can worsen reactions)
• Whether you had your period when you had the allergic reaction (in rare cases, menstruation is a necessary factor for an allergic reaction to happen)
• Whether you were ill at the time (infections can worsen reactions)
• Whether you have been sleeping well and / or have been under any particular stress recently (fatigue and stress can worsen symptoms)
• Whether your reactions always seem to happen during hot or cold weather (temperature can also be a necessary factor for a reaction to happen) or pollen season (you may have a pollen-food allergy which is exacerbated during the relevant pollen season)

Your allergist may also want to know:

• Whether you have had a blood transfusion recently—in rare cases, this can cause someone to acquire a food allergy, although it’s a temporary conditiondue to there being food-specific IgE in the blood. A recipient may also have an allergic reaction because the blood donor ate something the recipient is allergic to and the allergens were still present in the blood when it was donated
• Whether you have had an organ or bone marrow transplant recently—in rare cases, this can cause a new food allergy. In these cases, the allergy is often long-lasting

Finally, it’s possible that there is something about your environment that has contributed to your allergy, such as pollution or pollen or dust or vapours from food processing.

Your allergist may find it interesting to know:

• Whether you live near a busy road
• Whether there is mould or a lot of dust in your home
• Whether someone in your environment smokes
• Whether you live near a place where crops are harvested or food is processed
• Whether you work in food processing or farming

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Questions about your dietary history

If you have had several reactions, in order to try to pinpoint what triggers them, a 2-3 week written record—a diet and symptom diary—covering most the points listed above is extremely helpful, as are a few other details.

The allergist will want to know:

• Everything you have ingested—don’t forget condiments, sauces, snacks and sweets, even gum—and remember to list your drinks, especially alcoholic ones
  • When you ate or drank it (or touched or inhaled it)—date and time
  • Where you were at the time (e.g. at home, in school, in a restaurant, at the gym, on holiday, playing with the dog, doing a hobby)
  • Any medications you took / exercise you did around mealtimes
  • Detailed descriptions of your symptoms, their length and their severity
• Whether there are any foods that you generally dislike and avoid and why (sometimes people dislike food that they are allergic to—this is especially the case for young children)
• Whether there are any cultural or religious factors affecting the foods you eat
• Whether you have a known intolerance to colourings and/or preservatives

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Questions about your general medical background

Your medical background, current medications, and family history could all contribute towards your food allergies.

Your allergist will want to know:

• Whether you have any known allergies or intolerances, especially allergies to insects like dust mites or cockroaches (they can cross react with shellfish) or latex and/or pollen (they can lead to cross reactions with certain fruits and vegetables)— this will also affect which skin/blood tests the allergists orders done
• Whether you have any resolved allergies (for instance, you were allergic to milk when you were a child, but you outgrew the allergy, or you used to have eczema when you were an infant, but outgrew the condition—sometimes allergies can come back)
• Whether you have other medical conditions (this could affect your treatment)
• Whether you take any medications regularly and, if yes, which ones—include any general medications, including the Pill, and any allergy-related medications such as antihistamines, topical or oral corticosteroids, and whether you own/have used an adrenaline autoinjector—and whether you’ve suffered any side-effects
• Whether you’ve had any acute infectious diseases
• Whether any of your first-degree relatives—parents, brothers, sisters—have (had) either asthma, eczema, hay fever, food allergies (if yes, which)

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Questions about your child

If you are there for your child, the allergist will want to know:

About your child’s symptoms and dietary history

• Does your child have problems with any of the usual suspects?
  • Cows milk / egg / peanuts / tree nuts (e.g. walnuts, hazelnuts, almonds, Brazil nuts, cashew nuts) / sesame / wheat / fish / shellfish / legumes and pulses (soya, chickpea, kidney bean, lupin, baked beans) / fruits/vegetables (e.g. banana, kiwi fruit, potato, chestnut, tomato, avocado)
• If yes, how old were they when they first started showing symptoms?
• What was the most recent reaction like?
  • What was the reaction (e.g. rash, stomach ache, vomiting, wheezing)
  • How long was it after the child had eaten and how long did it last?
  • How much had they eaten? Was it cooked or raw?
  • Were they given any medications and, if yes, which medications and did they work?
• Was it the first time that they had reacted to this food? If not,
  • How often do they get these symptoms?
  • Are the symptoms generally similar each time?
  • Do they resolve by themselves?
• Have they ever had reactions on contact with food—e.g. touching the food, kissing a parent who has eaten the food? (Skin rashes upon exposure to raw or lightly cooked egg is common in children who are allergic to eggs)
• Do they ever avoid or refuse to eat certain foods? (Young children sometimes show dislike for or refusal to eat a certain food that they are later confirmed to be allergic to—possibly because of mild reactions that they have experienced when trying the food. When children refuse to eat several different foods, this could be due to an underlying eating disorder)

Whether your child was breast-fed

• For how long? Was it partial or exclusive?
• If exclusive, did the mother avoid any foods or consume a lot of any foods while breastfeeding?
• At which age did your child started drinking formula and / or (cow’s) milk?
• Which type of formula did you use (e.g. soy or hydrolysed milk)?
• At any point, did you have to change the formula to another and, if yes, which one?
• How well did your child feed—was it easy, or did they seem uncomfortable?
• Were there any problems weaning?

About your child’s symptoms as an infant

• Were they irritable?
• Did they have problems sleeping?
• Did they cry persistently?
• Did they arch their back often?
• Did they have colic?
• Did they vomit or have reflux (bring up small amount of milk, not the same as vomiting)?
• Did they have constipation / show signs of straining?
• Did they cry when their bowels were opened?
• Did they have early-onset severe eczema? (This could increase their risk of having an IgE-mediated food allergy, particularly milk, egg and peanut)

About your child’s symptoms now (if older)

• Do they often have a blocked or runny nose? (They could be allergic to pollen and, by extension, to certain fruits or vegetables)
• Doe they tend to have respiratory symptoms (cough / wheeze)?
• Do they have blood or mucus in their stool?
• Do they have difficulty swallowing / food sticking?
• How well do they sleep?
• Do they have gastrointestinal symptoms or skin rashes? These are classic symptoms of late-onset, non-IgE-mediated reactions to food, which include coeliac disease, eosinophilic esophagitis (EoE—which affects the oesophagus) food protein-induced enterocolitis syndrome (FPIES—which affects the small intestine), or proctocolitis (which affects the large intestine). The most common symptoms are diarrhoea, vomiting, bloody stools, eczema and hives, and the most common triggers are dairy, wheat, soy, rice and red meat
• Have they ever had a rash after touching party balloons? (They could be allergic to latex and, hence, certain fruits and vegetables)

Whether this possible food allergy is compromising dietary intake

• Does your child have a healthy appetite, do they enjoy eating?
• Has your child at any point failed to gain weight?
• Are they small for their age? Nutritional deficiencies can lead to young children being smaller than average

About the health of other family members

• Do the parents have any kind of allergies?
• Does your child have siblings and, if yes, do they have allergies?

The allergist may want to know:

About the home environment

• Whether you live near a busy road
• Whether anyone smokes in the home
• Whether you live near an industrial area / farmland
• Whether you have pets

About how the allergy is affecting the whole family

• How it affects the child at school / nursery
  • including school meals / events / trips
• How it affects the family’s mealtimes
• How it affects the family’s leisure time (e.g. parties, holidays)
• How it affects the family’s sleep

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You prepare for the appointment by..

Getting your information ready

Being ready to answer the allergist’s questions will save time for you to ask your own during the limited time you have available.

Before your appointment with the allergist:

• Make sure that your GP either forwards relevant medical records to the allergist or gives you the information you need to take with you
• If you have a regular pharmacist, you may be able to ask them for a printout of all your current prescriptions, if not, you can take photos of the labels of the medications you are taking
• Make a list of any supplements that you’re taking (they can cause allergic reactions too)
• Write down key personal information, including:
  • whether you or any of your close relative have known allergies
  • whether you’ve been ill recently or have ever had any acute infectious disease (think flu or stomach bug you caught on vacation)
  • whether you’ve suffered any major stresses or recent life changes (like a move or a new job)
• Write a diet and symptom diary lasting 2 to 3 weeks if possible
  • You might want to take photos if the symptoms are obvious, like a rash or swelling
• Save the labels of processed foods and/or make a list of the ingredients in home-cooked meals you suspect of provoking reactions

Preparing your own questions

Write down the questions you may want to ask the allergist, such as:

About the allergy:

• Could my symptoms be caused by something other than an allergy?
• What is the difference between a food allergy and an intolerance?
• What should I do if I accidentally eat my allergen?
• Will touching or smelling my trigger food provoke a reaction?
• How can I tell if I’m having an allergic reaction? What symptoms should I look out for?
• What should I do if I experience a severe allergic reaction? What medication do I need to take and when?
• Is my condition likely to be temporary or permanent?

About the diagnosis/treatment:

• What kinds of tests will I need? Is there anything I have to do to prepare for them?
• What are my treatment options?
• What can I expect from my treatment?
• Should I see a specialist? If yes, what will it cost and will my insurance cover it?
• What types of medications are available? Are there side-effects?
• I also have <other> health conditions; how can I best manage these conditions together?
• (If cost is a factor) Is there a generic alternative to the medicine you’re prescribing me?

About managing the allergy:

• What foods do I need to avoid?
• Can other people in my environment eat my food trigger or do I need to remove it from my house?
• Do I need to avoid products with precautionary allergen labelling statements such as ‘May contain’?
• Should I wear a medical identification bracelet? Where can I get one?
• What precautions do I need to take when I eat out / go on holiday?
• Are there any other lifestyle changes I can make to avoid having reactions?
• Where can I get more information about this—do you have any printed material that I can take home or websites that you can recommend visiting?

If you’re seeing the allergist for your child, you may also want to ask:

• Is my child likely to outgrow their allergy? If yes, how often should they be retested?
• Are there alternatives to the food(s) that trigger my child’s symptoms?
• How can I help keep my child safe at school / on play dates?
• Is immunotherapy an option? (Although food immunotherapy is generally not part of a standard clinical offering, children are more likely to be offered the opportunity to undertake treatment than adults and treatment for some foods—i.e. peanut—have been medically approved for widespread use)

List the questions from most to least important in case your time runs out.

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Then what?

If you haven’t been referred by a GP or don’t have any medical records, you will probably have to undergo a physical exam (e.g. blood pressure, heart and respiratory rate) to assess your general health.

If the allergist suspects an IgE-mediated food allergy based on the answers you have given them, they will typically arrange for you to have a skin-prick test and/or a blood test.

You may be asked to undergo the skin prick test (often done by a nurse or doctor’s assistant) and perhaps give a sample of blood during your first consult, after you’ve answered the allergist’s questions. A skin prick test will only be possible if you’re not taking antihistamines or have stopped taking them 3 to 5 days before the appointment, because they can interfere with the results of the test.

Skin (and blood) tests are sensitive but not very accurate so if they show positive results, the allergist will have to refer back to your clinical history to try and figure out the offending allergen(s).

If you have a suspected IgE-mediated food allergy and a history of moderate to severe reactions, you may be offered:

• prescription medication to deal with specific symptoms, such as topical steroids or anti-IgE medications
• an adrenaline autoinjector or a prescription for one

If your medical history and your test results are conflicting but an allergy to food is still suspected, you may be asked to come back for an oral food challenge. The test (including observation time) typically takes up to 8 hours. Due to the time and effort involved, oral challenges are rarely ever carried out.

If you have a history of reactions occurring after exercise—potential food-dependent exercise-induced anaphylaxis (FDEIA)—you may be asked to come back and undergo a specialised oral food challenge. The whole test can take up to 4 days, depending on how many factors need to be checked and, because of the very individual nature of these types of reactions, these challenges often don’t produce any symptoms. As a result, they’re even less likely to be carried out than regular oral food challenges.

If you must exclude foods from your diet, you may be given the option to see a dietician who can guide you in finding suitable replacements for the omitted foods. Nutritional deficiencies are a much greater risk for young children who need to grow, and far less of a risk in adults, although people who are avoiding multiple foods can be at risk.

If the allergist suspects a non-IgE-mediated food allergy or another type of food-induced disorder, skin and blood tests will often be useless because they exist only to detect food-specific IgE antibodies. Then, you may get a referral to see a gastroenterologist or other specialist who will want to do a different set of tests, such as different types of blood tests.

Whatever your next steps, your allergist should go through them with you and tell you what to expect. It’s a good idea to keep up with your record-keeping (e.g. symptom diary, photos, food labels) in between appointments, so that you can tell the specialist if you have had any further reactions or there have been any changes in your condition.

Good luck!

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