Paediatric Food Allergy and Intolerance Abigail Macleod, Associate Specialist, RBH
Ig E mediated food allergy Commonest cause of chronic disease in childhood up to 20% children But treatable, manageable and children >90% grow out of their allergies 20 deaths a year from anaphylaxis Divided into IgE mediated and non-ige mediated IgE mediated divided into anaphylaxis /non-anaphylaxis (may be genetically mediated) Enter footer here 01.08.2008 2
Genetics of IgE mediated allergy Not fully understood Likely to be able to predict severity of reaction Population based Filagrin gene mutations associated with atopic dermatitis and allergy Many other factors viral illness, poorly controlled asthma, sunlight Enter footer here 01.08.2008 3
Common allergens Milk Egg Wheat Soya Nuts Shellfish Others: coconut, sesame, pine nuts, Enter footer here 01.08.2008 4
Case study 11 month old Ate egg for the first time, developed urticarial rash immediately after eating a small spoonful. Possible swollen lips Taken to Westcall, given Piriton and observed Sent home 3 hours later Adrenaline or not? Advice to parents? Helpful investigations? Enter footer here 01.08.2008 5
Case study 1 Allergy reproducible, do not admit for diagnostic testing RAST unnecessary and expensive Oral antihistamine (cetirizine) Green allergy action plan Referral to allergy clinic Advised to avoid egg in lightly cooked form (or all egg if has never eaten egg before) Never take away what they are eating Enter footer here 01.08.2008 6
Case study 1 Seen in clinic and SPT 5mm (positive) Review around time of second birthday SPT<3mm (negative) For oral food challenge Enter footer here 01.08.2008 7
Skin Prick Testing Enter footer here 01.08.2008 8
Skin prick testing Main form of diagnostic testing and monitoring Shows sensitisation Cheap Easy Immediate results Helpful in connection with history Not useful for random testing Monitoring improvement Enter footer here 01.08.2008 9
RAST testing Expensive ( 25 per substrate) plus cost of blood test Invasive Long time for results Useful in combination with SPT Can be done if child on antihistamines Useful in severe eczema Enter footer here 01.08.2008 10
Case study 2 13 week old boy Initially breast fed 8/52 weaned onto formula vomited after every feed Poor weight gain, worsening of eczema Changed formula multiple times with the same symptoms IgE or non IgE mediated? Alternative milk? Emergency medicine? Enter footer here 01.08.2008 11
Case study 2 Milk - 600,000 / year on hydrolysed milk formula Hampshire PCT Changed to Nutramigen, then Nutramigen 2 Map of medicine milk prescribing algorythm Symptom improvement in 48 hours likely IgE mediated Symptom improvement in 1-2 weeks likely non IgE mediated Recommend fully hydrolysed formula Review at 1 year allergy clinic SPT, unless severe eczema and then see asap Enter footer here 01.08.2008 12
Case study 2 SPT positive to milk and soya Continue on hydrolysed formula Can add in other plant based milk For repeat SPT at 2 years Non-IgE mediated milk allergy, may develop into IgE mediated milk allergy especially with severe eczema Should always have allergy clinic referral before re-introduction of cows milk protein Enter footer here 01.08.2008 13
Case study 2 If SPT negative referral for milk challenge If passes OFC, may still have non IgE mediated allergy Will have secondary Lactose intolerance Slow re-introduction of cows milk protein Milk Ladder -?Whey or casein based allergy Cooked hard cheese Hard cheese Custard / yoghurt Doorstep milk Enter footer here 01.08.2008 14
LEAP and EAT studies Study of thousands of infants and children Do we wean early and onto wide range of food? Do we avoid allergens? Enter footer here 01.08.2008 15
Nut allergy Tends to persist longer, but may still grow out of it Allergy to one nut exclude all nuts, but this is changing May contain traces of Airborne reactions Nut free school? / aeroplane? Conkers/ acorns? One adrenaline pen or two? Immunotherapy Enter footer here 01.08.2008 16
Case study 3 3 year old given peanut butter sandwich by grandmother After one bite, spat out food and screamed Urticaria, lip swelling, coryzal ++, redness Dialled 999 and given adrenaline pen by ambulance crew Bought to A and E Next steps.. Enter footer here 01.08.2008 17
Case study 3 Always admit if received adrenaline Biphasic response Referral to allergy clinic Adrenaline autoinjector Oral antihistamine Allergy action plan? Medic alert bracelet Review at preschool, year 2, year 6 and year 11? Medically induce anaphylaxis Enter footer here 01.08.2008 18
Scombroid reaction Resembles allergic reaction to fish Due to eating decaying fish Large amounts of histamine consumed SPT negative Not reproducible Notifiable Enter footer here 01.08.2008 19
Salicylate reactions Contact reaction around the mouth High salicylate foods: Fruit: tomato, apples, strawberry, kiwi, grapes, plums Some cheese Marmite Do not recommend avoiding salicylates unnecessary Peel and cook fruit and vegetables Enter footer here 01.08.2008 20
FPIES Food protein induced enterocolitis syndrome Non IgE mediated severe reaction Common to milk/ soya/ wheat/ oats/ rice/ (meat/ chicken/ fish) Profuse d and v may present shocked (tryptase helpful) Symptoms return when food re-introduced Adrenaline not useful Difficult to diagnose, difficult to monitor Should be managed in tertiary allergy unit Most children grow out of FPIES by age 3, open door, letter of explanation Enter footer here 01.08.2008 21
Thank you Any questions? Enter footer here 01.08.2008 22
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