Version July 2025
INTRODUCTION —
Respiratory tract symptoms observed with food hypersensitivity reactions include nasal congestion, rhinorrhea, sneezing, itching of the nose and throat, coughing, and wheezing [1]. Food allergen exposure is usually through ingestion, but the inhalation of food proteins in the form of dust or aerosolized particles may also trigger respiratory symptoms.
Isolated asthma or rhinitis secondary to food allergy is reported but is rare [2]. More commonly, respiratory symptoms of food allergy are accompanied by skin and/or gastrointestinal manifestations. Foods can elicit asymptomatic airway hyperreactivity or symptomatic asthmatic responses. In addition, systemic anaphylactic reactions often have a respiratory component. Occupational exposure to foods accounts for up to 25 percent of occupational rhinitis and asthma [3].
This topic review covers the etiology, diagnosis, and clinical manifestations of respiratory symptoms related to food allergy. Other clinical manifestations of food allergy, oral allergy syndrome, and food-induced anaphylaxis are discussed separately. Occupational asthma and rhinitis are discussed in more detail elsewhere (See "Clinical manifestations of food allergy: An overview" and "Clinical manifestations and diagnosis of oral allergy syndrome (pollen-food allergy syndrome)" and "Food-induced anaphylaxis" and "Occupational rhinitis" and "Occupational asthma: Definitions, epidemiology, causes, and risk factors".)
EPIDEMIOLOGY —
Respiratory symptoms as a component of systemic allergic reactions triggered by food occur in up to 50 percent of patients [4-7]. However, isolated respiratory compromise (persistent cough, wheeze, change in voice, stridor, difficulty breathing) is rare. As an example, of 314 positive food challenges in one-year-old infants, 4 percent experienced respiratory or cardiovascular compromise, and only one had isolated respiratory symptoms [2,8].
ASSOCIATIONS BETWEEN FOOD ALLERGY AND ASTHMA
Atopic march — Children with a family history of atopy and sensitization to food proteins in early infancy are at high risk of subsequent respiratory allergic disease. This progression from atopic dermatitis/eczema to food allergies, environmental allergies/allergic rhinoconjunctivitis, and then asthma is called the atopic or allergic march [9]. Cohort studies found that early childhood food allergy was associated with a risk of developing asthma (approximate odds ratio [OR] between 2 and 3) [10,11] and of allergic rhinitis (OR 2.7) [10]. Among participants in the National Health and Nutrition Examination survey 2005 to 2006, which used serologic tests to estimate food allergy, having a likely food allergy was associated with an adjusted OR of 3.8 for having current asthma [12]. In contrast, a cluster analysis of 398 children with atopic risk factors failed to show an association of food sensitization with asthma outcomes [13]. This finding was verified in an additional cohort of 3051 children. However, eczema and rhinitis did cluster with food sensitization.
Association with asthma severity — Food allergen sensitivity and food allergy are associated with increased asthma severity and worse asthma control.
●Food allergen sensitization was examined in children with asthma living in an urban environment in the United States [14]. In vitro specific immunoglobulin E (IgE) testing to six common food allergens (hen's egg, cow's milk, soy, peanut, wheat, and fish) was performed. Forty-five percent of the children were sensitized to at least one food. Children sensitized to foods had higher rates of hospitalization for asthma exacerbations and required more treatment with glucocorticoids.
●Nineteen children with severe exacerbations of asthma requiring mechanical ventilation were investigated [15]. These patients had an increased risk of food allergy (OR 8.6, 95% CI 1.8-39.7) and frequent asthma admissions (OR 14.2, CI 1.8-113.6) compared with controls. Fifty percent of the cases had food allergy versus 10 percent of the controls.
●Another group studied a cohort of 203 urban adults (mean age 48 years) with persistent asthma. Patients with self-reported allergies to more than one food had increased asthma hospitalizations, emergency department visits for asthma, and use of oral glucocorticoids [16].
Marker for severe or fatal anaphylaxis — Having asthma was long considered a potential risk factor for severe or fatal food-induced allergic reactions because respiratory symptoms are common in fatal anaphylaxis [17] and most victims of fatal food-induced anaphylaxis have asthma [18]. However, an analysis of factors related to severe anaphylaxis in a European anaphylaxis registry failed to identify comorbid asthma as a risk factor [19]. A subsequent meta-analysis found that a diagnosis of asthma was not a risk factor for severe food allergy reactions and well-controlled asthma was unlikely to be a useful predictor, although it was unclear if poor asthma control or more severe asthma were markers of severe or fatal anaphylaxis [20]. Comorbid asthma may not be a good marker of risk for severe food-induced anaphylaxis, simply because asthma is common in persons with food allergy and most will not have severe or fatal anaphylaxis [21]. However, given that respiratory compromise is a prominent feature of severe or fatal anaphylaxis, poorly controlled asthma with increased airway hyperreactivity could nonetheless be a risk factor for severe or fatal food-induced reactions. (See "Fatal anaphylaxis".)
ETIOLOGY
Risk factors — Factors favoring the acquisition of food allergy with respiratory manifestations in adulthood include sensitization to pollens and occupational exposure by inhalation [3,22]. (See "Pathogenesis of food allergy".)
Allergens — Anaphylactic reactions, including significant respiratory symptoms, to foods are most often caused by peanut, tree nuts, or seafood, and respiratory symptoms are reported in approximately 50 percent of reactions to these foods [5-7].
Wheat (baker's asthma) and seafood are common triggers for occupational rhinitis and asthma, but it is theoretically possible for any aerosolized food protein to trigger respiratory allergic reactions in sensitized persons. Additional documented triggers include hen's egg, cow's milk, various grains, fruits, vegetables, seeds, meats, and other foods [3].
A high percentage of patients with asthma perceive that food additives worsen their respiratory symptoms. However, blinded challenges often do not confirm these triggers. Several different food additives, including sulfites and sodium benzoate, have been implicated in adverse respiratory reactions. These types of reactions are discussed in greater detail separately. (See "Allergic and asthmatic reactions to food additives".)
Routes of exposure — Sensitization and food-induced allergic reactions most commonly occur through the gastrointestinal tract with food ingestion but can also occur via the skin (more common in children) or via inhalation (more common in adults with occupational exposures).
Ingestion — Oral ingestion is the primary route of exposure to foods that can cause or exacerbate respiratory symptoms. An internet-based survey of 51 anaphylactic reactions to foods showed that, while most of these reactions (78 percent) occurred after ingestion, 16 percent occurred following exclusive skin contact, and 6 percent occurred after inhalation of the food allergen [23]. These reactions will be discussed in more detail below. (See 'Respiratory manifestations' below.)
Inhalation — Several investigations have highlighted cases of respiratory allergic disease precipitated by inhalation of airborne food allergens [24-30]. These exposures occur in both occupational and nonoccupational settings. Prolonged exposure to high levels of food allergens, such as occurs in occupational settings, increases the risk of sensitization [22]. Risk factors include ones related to the workplace (eg, poor ventilation, lack of training on safety and health), as well as individual factors such as atopy. Key observations regarding inhalation exposure are demonstrated by the following studies:
●Highly allergic persons may react when exposed to aerosolized allergen in a seafood restaurant [24]. Exposure to airborne fish allergens can also occur at open-air fish markets [29,30].
●Asthma symptoms can occur in sensitized children when food allergens such as fish, shellfish, eggs, chickpeas, or buckwheat are cooked in a confined area [25,26]. Both acute and late-phase respiratory symptoms were demonstrated in one of these studies [26].
●Respiratory exposure through aerosolization of food via cooking can trigger other symptoms such as urticaria [26].
●Variables related to whether aerosolized food triggers symptoms may include the degree of exposure and the sensitivity of the patient (ie, lower threshold allergen dose) [26].
●Peanut butter is an oily substance, and the aroma does not appear to contain sufficient protein to induce respiratory reactions [31].
These data highlight the importance of considering foods as aeroallergens in patients with coexistent food allergy and allergic asthma. Dietary avoidance alone may not be sufficient for these patients. Further environmental measures may be required to limit exposure to aerosolized food. Additional information about the risks and avoidance strategies regarding inhalational exposure are discussed separately. (See "Management of food allergy: Avoidance".)
RESPIRATORY MANIFESTATIONS —
Respiratory symptoms of food allergy are usually accompanied by skin and/or gastrointestinal manifestations. Isolated asthma or rhinitis caused by an allergic reaction to a food is uncommon. In adults, isolated asthma or rhinitis is most often seen in the setting of an occupational exposure. Asthma symptoms triggered by food allergy are primarily seen in children, particularly those with atopic dermatitis. (See "Anaphylaxis: Emergency treatment".)
Upper respiratory symptoms — Nasal symptoms are commonly seen as part of systemic food-triggered allergic reactions [32]. However, isolated rhinitis in response to foods is rare. An exception is occupational rhinitis in food industry workers. (See "Occupational rhinitis".)
Many patients associate the ingestion of milk and other dairy products with an increase in the production and thickness of nasal secretions. However, objective studies do not support these complaints, and they are unlikely to be due to a specific allergic reaction [33].
The role of food allergy or any allergy in recurrent serious otitis media (otitis media with effusion) has been proposed, but this association is unproven, and allergy evaluation is not specifically recommended in guidelines [34,35].
Asthma — Most studies regarding food allergy and respiratory tract symptoms have focused on patients with an underlying history of asthma. The association between food allergy and asthmatic symptoms is seen mainly in children, especially those with atopic dermatitis, and occurs primarily after ingestion of the food allergen (see 'Epidemiology' above). In adults, isolated asthma as a manifestation of food allergy is most commonly related to inhalation exposure and is seen primarily in food industry workers [3,22]. Patients with both asthma and food allergies are at increased risk for morbidity and possibly mortality from these conditions. Thus, close follow-up of these patients is advised. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors" and "Occupational asthma: Clinical features, evaluation, and diagnosis".)
Bronchospastic respiratory symptoms are also seen in children with atopic dermatitis and food allergy when they undergo food challenges. Respiratory symptoms are less commonly seen in children with non-IgE-mediated food allergy with primarily gastrointestinal manifestations.
●In a previously cited United States study, children with atopic dermatitis undergoing blinded food challenges were monitored for respiratory reactions [32]. Seventeen percent of children developed wheezing during positive food challenges. Eighty-eight patients were monitored with pulmonary function testing during food challenges. Fifteen percent (13 of 88) developed lower respiratory symptoms, including wheezing. However, only six patients had a >20 percent decrease in forced expiratory volume in the first second (FEV1). Wheezing as the only manifestation of the respiratory reaction was a rare observation. (See 'Upper respiratory symptoms' above.)
●In a review of 313 oral food challenges in children at one center, reactions on challenge were more likely if the children had asthma [36].
●In a prospective survey of 300 school-aged children living in an urban environment, 24 percent had clinician-diagnosed food allergies. Those with food allergies had an increased risk of hospitalization, worse lung function, and more use of asthma controller medications than those without food allergies [37].
Airway hyperresponsiveness — Ingestion of a food to which the patient is allergic may result in increased airway hyperresponsiveness (AHR) despite the absence of acute symptoms. This has been demonstrated in pediatric patients with moderate to severe asthma.
●In one investigation, 26 children with asthma and food allergy were evaluated using methacholine inhalation challenges before and after blinded food challenges [38]. Twelve of the 22 patients with positive food challenges had respiratory symptoms (cough, laryngeal reactions, and/or wheezing). The remainder of children with positive food challenges exhibited laryngeal, gastrointestinal, and/or skin symptoms without lower respiratory symptoms. Significant increases in AHR were documented in 7 of the 12 patients who experienced respiratory symptoms during these challenges. Increased AHR was also noted in one patient without respiratory symptoms during a positive challenge and one patient after a negative challenge. A similar study noted a significant increase in AHR among children with asthma without respiratory symptoms following a positive food challenge [39].
●Food allergy is less likely as a cause of increased AHR in adults than in children. As an example, in a study of 11 adults with asthma, a history of food-induced wheezing, and positive skin prick tests to the suspected foods, an equal number of patients had increased AHR by methacholine inhalation challenges after blinded food challenges to either food allergen or placebo [40].
●Three small studies indicate that 40 to 50 percent of patients with food allergy in the absence of asthma might also have increased AHR [41-43].
These studies may raise the concern, particularly for children, that a chronically ingested food could contribute to AHR and asthma in the absence of acute symptoms, but the data do not support this concern, as only a single patient had increased AHR after having tolerated a food challenge, and AHR also varied even after placebo food challenges in adults.
Anaphylaxis — Anaphylactic reactions that include respiratory symptoms can occur after the oral ingestion of a food allergen. This topic is covered in detail elsewhere. (See "Food-induced anaphylaxis".)
As described above (see 'Inhalation' above), systemic allergic reactions caused by inhalation of allergens have been described but appear to be uncommon [44].
DIAGNOSIS —
The medical history supplemented with appropriate laboratory testing and food challenges can provide useful information in evaluating patients with respiratory symptoms that may be induced by food allergy. Further workup for IgE-mediated allergy is not generally indicated if no specific foods are implicated in the history and if skin tests or in vitro measurements of specific IgE to foods are negative.
Food is unlikely to be the problem if respiratory symptoms persist after food elimination diets are implemented. Respiratory symptoms that recur after a regular diet has been resumed should be evaluated with a food challenge. (See "History and physical examination in the patient with possible food allergy" and "Diagnostic evaluation of IgE-mediated food allergy" and "Oral food challenges for diagnosis and management of food allergies".)
Studies have demonstrated that foods can elicit airway hyperreactivity and asthmatic responses. Thus, evaluation for food allergy should be considered in patients with:
●Recalcitrant or otherwise unexplained acute, severe asthma exacerbations
●Asthma exacerbations following ingestion or inhalation of particular foods
●Asthma and other manifestations of food allergy (eg, anaphylaxis, moderate-to-severe atopic dermatitis)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Prevalence of respiratory symptoms triggered by food allergy – Respiratory symptoms as a component of systemic allergic reactions triggered by food ingestion occur in up to 50 percent of patients. However, isolated food-induced respiratory symptoms from ingestion are rare. In adults, isolated asthma or rhinitis is most often seen in the setting of an occupational exposure. (See 'Epidemiology' above and 'Respiratory manifestations' above.)
●Associations between food allergy and asthma – Allergic sensitization to food or having food allergy in the first few years of life may be predictive of later respiratory allergic disease, including allergic rhinitis and asthma. Food allergy and food allergen sensitization may also be a marker for increased asthma severity. (See 'Associations between food allergy and asthma' above.)
●Route of allergen exposure – Food allergen exposure is usually through ingestion, but the inhalation of food proteins in the form of dust or aerosolized particles may also trigger respiratory symptoms. (See 'Routes of exposure' above.)
●Types of respiratory symptoms triggered by food allergy – Respiratory tract symptoms observed with food hypersensitivity reactions include nasal congestion, rhinorrhea, sneezing, itching of the nose and throat, coughing, and wheezing. Ingestion of a food to which the patient is allergic may result in increased airway hyperresponsiveness (AHR) despite the absence of acute symptoms. (See 'Respiratory manifestations' above.)
●Diagnosis – Isolated asthma or rhinitis caused by an allergic reaction to a food is rare. Thus, we do not routinely test persons with asthma or rhinitis without other signs of a systemic reaction for food allergies. One exception is in adults with a suspected occupational exposure. (See 'Diagnosis' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges John M James, MD, who contributed to earlier versions of this topic review.
