Clinical Manifestations and Management of Food Allergy Adrian Sie Consultant in paediatrics, Wishaw General, Lanarkshire April 2013
To do Bring Allergy plan Prevention photo
Contents Is it allergy? How do I prevent anaphylaxis (should they get an Epipen)? What follow up?
Contents cont Common issues for patients & families Isn t it allergy? What s allowed and what isn t School, holidays, parties, eating out Quality of life
Questions FH of food allergy (Dad anaphylaxis), what should mum do about infant feeding? Obvious reaction to peanut, do they need a test? Previous egg allergy, have they outgrown it? Bad eczema, Mum thinks it must be the diet
N=518 Lanarkshire database
Prawn Soya Tomato Kiwi Wheat Strawberry Cashew Fish Sesame Lentil Pulse Milk Nut Peanut Egg 0 10 20 30 40 50 60 70 80 90 100
Prevention For formula fed, limited (conflicting) evidence for hydrolysed vs normal 2009 study found no link between antenatal nut intake, intake during breast feeding or infant intake and peanut allergy Current LEAP and EAT studies
Weaning Committee on Toxicology withdrew recommendations 3 years ago Avoid giving your baby certain foods [before 6/12], as they may cause food allergies ie wheat, milk, egg, nuts, seeds, fish Early weaning <4/12 increases risk Breastfeeding for 4/12 may prevent severe eczema No benefit from delayed weaning >6/12
Diagnosis? Reaction to naan bread Reaction to hummus [known peanut allergy] Reaction to Aldi waffle [known lentil allergy] Reaction to pizza
Symptoms and Signs Skin Tongue/lips Nose Eye
Eczema Cough Throat closing over Grunting Fainting Diarrhoea Allergy?
Nice type 1 chart
Not Allergy? I m allergic to that Idiopathic urticaria/angioedema I hate that Chemical GORD, infantile colic, constipation, nappy rash
Anaphylaxis? 4yr old probably ate some nuts at party Itchy rash, vomiting, wheezy In A&E bright but wheezy, tachycardic, sats 93% Is this: a) Anaphylaxis b) Mild anaphylaxis c) Severe allergic reaction
Anaphylaxis? cont Acute onset, skin/mucosal involvement, plus respiratory or cardiovascular compromise (egbronchospasm) [EAACI position paper 2007] How would you manage?
Would you test? 10yr old, known peanut allergy, no reactions for years 2yr old, obvious reaction to first taste of nuts (peanut butter) 3yr old, previous egg allergy as baby, now eating hidden egg
Would you test? 1 10yr old, known peanut allergy, no reactions for years Yes, but unlikely to change over 12yrs
Would you test? 2 2yr old, obvious reaction to first taste of nuts (peanut butter) Helps prognosis Other nuts Co-sensitivities
Would you test? 3 3yr old, previous egg allergy as baby, now eating hidden egg No, unless high risk
Diagnostic accuracy please! Nut allergy vs Peanut allergy Peanut anaphylaxis Possible peanut allergy (SPT neg) Possible peanut allergy (IgE pos)
Preschool allergic reactions 0.81 per year, half having more than 1 50% involved people other than parents 11% purposeful Of severe reactions, 29% treated with adrenaline
Food knowledge? Labels, shopping Avoidance Eating out Parties Know your dietician! Grandparents Alternatives, nutrition
Traces May contain traces of peanut Made in a factory where nuts are used Most families allow at least familiar foods Risk assessment approach
All nuts? Tree nuts? Coconut? Seeds?
Management of Allergic Reaction Scenario Recognize mild vs severe symptoms? Use of antihistamine? Poor response?
Management of Anaphylaxis Pen carried? How many? In date? Indications for pen Use of pen Use of other medicines Wait on ambulance
Other issues Asthma, hay fever etc High risk? Epipen? Medicalert? Cross-sensitivity School/nursery Holidays
Other issues cont Prognosis? Challenge? Transition Patient support groups Allergy UK Anaphylaxis Campaign CYANS
High risk kids Lots of allergies esp nuts, esp peanut Reaction with trace exposure Previous anaphylaxis High test result Poor asthma control Teenagers Remote
High Risk behaviours Not reading labels Eating new things with lots of different ingredients Eating things that often contain nuts eg chocolate bars Not having allergy medicines to hand, not knowing how to use them Being away from home
Epipen Not used 2 out of 3 times Carried? In date? Recognize symptoms? Technique? Junior vssenior vs vials One or two? New version/jext/anapen? Online quiz/videos
Epipen quiz/video
Co-sensitivity Nuts Pulses Fish Fruit/Veg/Latex
Will it get better? Depends on the allergy Depends on the age Depends on the test result Depends on desensitization can recur!
Natural Course Cow's milk allergy starts in 1st year, often in first month, 85% become clinically tolerant by age 3yr Egg allergy usually in 2 nd year, 66% become tolerant by age 5yr Peanut allergy persists throughout adulthood in 80%
Emergency allergy plan Teacher awareness Peer awareness Catering awareness Exclusion, bullying School trips School
At home or in hospital? What with? When and where? Written plan? Challenge
Egg challenge clip
Desensitization Egg - 30% positive food challenges for desensitizers cf 49% for abstainers Milk - 11% positive food challenges cf 40% for abstainers In the abstainers, threshold of sensitivity lower, and symptoms more severe Current peanut tolerance studies
Support CYANS Allergy UK Anaphylaxis Campaign
CMPI Can affect exclusively breast fed! Constipation! Eosinophilic enteritis! Early or Late (non IgE) Diagnosis by Nutramigen! Not Lactose free! Avoid Soya under 6/12
Eczema NICE guideline Significant eczema with multiple suspected food allergies Moderate to severe eczema in infants Type 1 reactions
Egg allergy Raw (meringue) vs sloppy (scrambled) vs cooked (cake) MMR? Flu vaccine?
Idiopathic Urticaria Urticaria/angioedema Prolonged No clear trigger Recurrent? Rx Antihistamines
Chemical Salicylates Amines Benzoates Sulphites Histamine/Scombroid
Questions FH of food allergy (Dad anaphylaxis), what should mum do about infant feeding? Obvious reaction to peanut, do they need a test? Previous egg allergy, have they outgrown it? Bad eczema, Mum thinks it must be the diet
Summary Increasing problem Prevention difficult History, history, history Not all allergy is allergy
Summary cont What can we do better? Diagnosis Co-sensitivities Information: allergy plan, challenges Epipen support Hay fever, asthma Prognosis, incl risk Transition