Nutricia Paediatric Food Allergy Expert Meeting The speaker had sole editorial control over the content in this slide deck. Any views, opinions or recommendations expressed in the slides are solely those of the speaker and do not necessarily represent those of Nutricia.
Novel approaches to optimising paediatric dietetic food allergy services Rachel De Boer Paediatric Allergy Dietitian Guy s and St Thomas Hospital December 2016
Challenges
What do you see as the major challenges to Paediatric Allergy Dietetic services? 1.Increasing demand/increasing prevalence 2.Complex patients 62 3.Lack of funding/support 4.Changes in management strategies e.g. baked egg, milk introduction, safe nut introduction 14 15 5.All of the above 1 0 0 6.None of the above 1 2 3 4 5 6
Increasing demand
Increasing prevalence Prevalence of food allergy in children increasing Food allergy in children= 6-8% Up to 10% of 1 year olds are food allergic Severity also increasing: 38.7% food allergic children experienced a severe reaction Rates of hospitalisation for food-induced anaphylaxis increasing Anagostou K et al. Children. 2015, 2, 439-452 Gupta et al. Paediatrics. 2011; 128;e9-17 NHS Digital data 2016
Rates of allergy admissions to hospital = Number of hospital admissions Data from NHS Digital 2016
Increasing demand Childrens Allergy Service at Guy s and St Thomas NHS Referral patterns: New weekly referrals increasing from 54 to 76 per week in 3 years 13% increase in the past year Increased from est. 2800 to 3950/yr Financial year
Increasing demand Reason for increasing demand Increasing prevalence Improved recognition/diagnosis Increased awareness amongst HCP Increased awareness amongst public Gupta et al. Paediatrics. 2011; 128;e9-17
Complex caseload Prevalence, persistence and severity
Rates of resolution of food allergy N Age Diagnosis(Yr) Follow up age (Yr) IgE Remission Non-IgE Milk Danneus A et al (1981) 47 <2 6 29% 74% Host A et al (1997) 39 <1 3 76% 100% Bishop J et al (1990) 100 <2 5 67% 86% Skripac (2008) 807 <2 4 19% - Egg Ford RPK et al (1982) 25 <2 4 44% - Laske N et al (2006) 119 <2 5 52% - Peanut Skolnick HS et al (2001) 223 <2 6.5 21.5% - Ho M et al (2006) 267 <2 4.5 19.6% - Wheat Pooton V et al (2006) 42 <2 5 50% -
Gastro-allergy Exponential rise in diagnosis of Non-IgE mediated GI Food Allergy Rise in EoE mirrors increased prevalence of allergic diseases Spergel et al:70-fold increase in prevalence of EoE from 1994-2011 Dietary management of Non IgE GI food allergies comprises 3 phases: Elimination phase: 4 food/6 food restrictions Food reintroduction/challenge phase Management phase Spergel JM et al Journal of pediatric gastroenterology and nutrition. 2009; 48:30 6. Best Pract Res Clin Gastroenterol. 2015 October ; 29(5): 771 781 Venter et al Ann Allergy Asthma Immunol 117 (2016) 468e471
Multi-system disease Concomitant co-morbidities in food protein induced GI allergies (Meyer et al 2013) Date from 437 children
Changing management strategies
Changing management Traditional management Current/Active management Strictly allergen avoidance Balancing act between Ensure nutritional sufficiency avoiding allergens and promoting acquisition of tolerance (Katz. J Paeds 2013) Educate on management of reactions Active attempts to induce tolerance Wait and wait for development of tolerance Slide credited to Dr Adam Fox
Natural History of IgE mediated milk allergy Skripak JM et al. The Natural History of IgE mediated Cow s Milk Allergy. JACI Nov 2007.
Safe nut inclusion Baked milk/egg introduction Desensitisa tion Active allergy management Early introduction of safe allergens Risk assessment Ladders on PALs
Potential Solutions Optimising dietetic services
Increasing demand: Problems we face space and capacity Twice monthly evening clinics: Evening Transition/adolescent clinics patients Weekend clinics Booked Dietitian phone call clinics
Dietitian-led Paediatric Allergy clinics Extending the role of a Dietitian: Utilises unique skill set of Paediatric Allergy Dietitians Follow-up patients triaged into clinic Inclusion/exclusion criteria Dietetic competencies (from BSACI/GSTT Nurse document): skin prick testing, AAI training, clinical decision making
Care pathways in food allergy Standard management i. Allergy specific advice ii. Optimisation of prevention and treatment of further reactions - written personal management plan/training iii. Minimising impact on quality of life iv. Nutritional support and monitoring by registered dietitian Complex Management (MDT setting) i. Involvement of clinical nurse specialist in paediatric allergy ii. Involvement/referral to allied healthcare professionals, ideally in joint allergy clinics e.g. specialist paediatric allergy dietitian iii. Expert psychosocial support iv. Further care, as detailed below
RCPCH Care Pathway Project: Allergy focused clinical history 3 screen questions Is there personal history of allergy? Are environmental exposures consistently related to symptoms? Is there a family history of allergy? 9 general allergy history questions 8 food allergy history questions 7 respiratory symptom questions 5 ENT symptom questions 5 skin symptom questions
Allergy focused Diet History Skypala et al, Clin Transl Allergy. 2015 Feb 19;5:7
Competencies BSACI Nurses competencies Skin prick testing AAI training EAACI AHP competencies in production
Optimising dietetic services Utilisation of parent education group CMA parent education groups Supermarket tours/ free from cooking sessions Online parent education videos
What are the different type of food allergies? Immediate vs Delayed Dairy free daily products what alternatives are available? I m allergic to milk what alternatives are available? I m allergic to egg What alternatives are available? Parents online education videos I m allergic to some nuts does this mean I need to avoid all nuts? When should I use my adrenaline injector?
Optimising dietetic services Utilisation of parent education group CMA parent education groups Online parent education videos Health technology: FoodMaestro/Tell the Doctor
FoodMaestro Healthcare portal Search for products by excluding allergens and/or ingredients Search for products containing an ingredient (research) Search for specifically named products Create patient product lists Create dynamically updated conditions based product lists Send products lists electronically to patients (paper free) Create product notes 31
Tell the Doctor Tell the Doctor: phone app and clinic dashboard App content and dashboard developed in conjunction with Dr Adam Fox and Dr Katherine Anagnostou, Evelina Children s Hospital, Guy s and St Thomas Hospital, London Data uploaded in real-time to the dashboard Project funded by App allows patients to input serious reactions and report back on how their allergies affect their daily living Doctor has information available at consultation via web-based clinic dashboard In clinical trial situation, investigators can see real-time data and intervene if necessary
Optimising dietetic services Utilisation of parent education group CMA weaning parent education groups Online parent education videos Health technology: FoodMaestro/Tell the Doctor/Spoonguru Primary prevention OFC clinics - Peanut/egg
Rapid access OFC s Early/optimal introduction of peanut/egg in high risk patients following LEAP/EAT studies Primary prevention Encourage inclusion SPT = 0 Advice to introduce of peanut 2-3 times/wk SPT 1 4mm Refer for OFC/SFC SPT 5mm +, Assume peanut allergic With thanks to Heidi Ball - criteria for Rapid access challenge clinic referral within Leicester Allergy Service
CMPA BDA accredited course for Dietitians Other initiatives Twitter: Allergy hour Allergy UK Dietitian-led phone call service
Further education
Further allergy education MSc Allergy Imperial & Southampton Each have stand alone dedicated food allergy modules Allergy Academy Allergy in Practice 3 x 2 day modules BDA Accredited Cow s milk allergy course Competency based learning
Summary As demand on our Paediatric Allergy services increases Dietitians are ideally placed to develop services, promote new initiatives Dietitians have the potential to provide holistic allergy care, reduce number of visits and allow Medical staff to see more new patients. Dietitians can successfully carry out an extended role, inc. SPTing and AAI training Use of Health-Technology and online parent education tools can be helpful to increase parental understanding and confidence
Which of the following initiatives would be useful to help optimise your Paediatric Allergy Dietetic services? 1.Dietitian-led follow up clinics 2.Phone clinics/skype clinics 43 3.Parents education groups 4.Online education videos 5. Use of Health technology 8 5 11 2 1 1 6. All of the above 7.None of the above 1 2 3 4 5 6 7
Thank-you for your attention Acknowledgements Dr Adam Fox Dr Kate Swan Ruth Chalmers Miriam Tarkin Heidi Ball Allergy UK