Childhood food allergy solving the puzzle

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Article

Authors

Charles, Ruth

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Nursing in General Practice

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Nursing in General Practice

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http://hdl.handle.net/10147/248811

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clinical review

Childhood food allergy: solving the puzzle There are numerous myths surrounding childhood allergy, but in fact allergy affects approximately 5% of children. Ruth Charles,
Paediatric Dietitian,
Ballinderry Clinic, St. Francis Hospital, Mullingar, Co. Westmeath Fact or fiction? • Food allergy is not common in infancy? • Consumption of milk and dairy products leads to mucus in the upper and lower respiratory tracts? • Goat and soy milk are suitable alternatives if cow’s milk allergy is suspected? • Allergy tests (skin prick and serum specific IgE) have no relevance in early infancy? • The next allergic reaction will be worse than the previous? These are just five of the most common myths that exist around food allergy – they are all untrue! It is not uncommon for food allergy to be mis – or undiagnosed especially considering that there is no fully resourced service for paediatric allergy in the Republic of Ireland. Food allergy in childhood does exist. It presents mainly in the community and primary care settings and affects 5-6% of young children.1 Milk, egg, peanut and treenut are the most common food allergens in children under 3 years: nut, fish and shellfish are more common in older children.

Food allergy often exists with other allergic diseases (mostly eczema, followed by asthma and rhinitis). The Allergy March2 is a concept that describes the relationships between them. What happens? On first contact with a food (consumed, inhaled, rubbed on skin, lips or into the eye) the immune system becomes sensitized to the allergen it contains. On subsequent contact (accidentally or otherwise), the immune system reacts resulting in symptoms within minutes, hours or days of the contact. The timing of the reaction is an important distinguishing feature between IgE mediated (usually rapid onset within minutes) and non IgE mediated (usually delayed onset from 2-48 hours) food allergy. The UK National Institute for Clinical Excellence (NICE) produced clinical guideline 116 in 2011 which is an excellent summary of best practice advice on the care of children and young people with suspected food allergies. 3 Lactose intolerance does not cause an allergic reaction. Con11

clinical review The Allergy March

Asthma Rhinitis Food allergy

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genital lactose intolerance is rare. Primary lactose intolerance is unlikely to become symptomatic until late childhood. Transient intolerance can result after any insult to the brush border of the intestinal epithelium where lactase production or its action is affected e.g. gastroenteritis. It usually resolves within 6-8 weeks, so the long term or indefinite use lactose free infant formula is unlikely to be helpful. Testing Serum specific IgE and food specific skin prick tests indicate sensitization to an allergen but do not always predict whether a child will or will not have an allergic reaction. This is further evidence of the importance of a focused clinical history and examination. NICE recommend that allergy tests should only be done by healthcare professionals with the appropriate com-

petencies to select, perform and interpret them and that skin prick tests should only be undertaken where there are facilities to deal with an anaphylactic reaction. 3
What is clear is that vega testing, applied kinesiology, hair analysis or serum-specific IgG and IgA have no role in the diagnosis of food allergy. 3 Remove food or not? If a particular food is suspected, but there is no evidence of any immediate or delayed reaction after it’s been eaten, then that food should not be removed from the diet and should be put back in if it has been removed.
Removing any food from a child’s diet is a major decision and there needs to be a clear rationale for so doing. The child and family will need significant support as there are many social issues to consider (quality of life, grocery shopping, cost etc.).

Signs, symptoms and differentials are described as follows: IgE mediated food allergy

Non IgE mediated food allergy

Skin Pruritus
 Erythema
 Acute urticaria – localised or generalised
 Acute angioedema – most commonly of the lips, face and around the eyes

Pruritus Erythema Atopic eczema

Gut Angioedema of the lips, tongue and palate
 Oral pruritus
 Nausea Abdominal pain Vomiting Diarrhoea

Respiratory (usually with one or more of the above) Nasal itching Sneezing Rhinorrhoea Congestion
 Cough
 Chest tightness Wheeze
 Shortness of breath Other Signs or symptoms of anaphylaxis or other systemic allergic reactions 12

Gastro-oesophageal reflux disease Loose or frequent stools
 Blood and/or mucus in stools Colicky abdominal pain/ Infantile colic
Food refusal or aversion
 Constipation
Perianal redness
 Pallor and tiredness
 Faltering growth in conjunction with at least one or more gastrointestinal symptoms above (with or without significant atopic eczema)

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clinical review The diagnosis relies on a comprehensive history with special focus on: 4 What happened?

Were the symptoms consistent with the features described above? Importantly, were there any features of anaphylaxis?

Timing.

Minutes to < two hours – immediate allergy: > two hours – possibly delayed allergy.

What food was suspected?


Any food may cause an allergic reaction but there are the usual suspects.

How much of the food was consumed?

IgE-mediated reactions may occur after exposures to tiny amounts of food or contamination.

Has this happened before?

Food allergy reactions often occur a number of times before the link is realised

What happened after the reaction?

Did the reaction progress?


How long did symptoms persist?

Urticarial reactions lasting longer than 24 hours are unlikely to be food allergy.


How did it resolve?

Were antihistamines required?

Does the child have any risk factors for food allergy?

Most notably eczema or other food allergies. Is there a family history?


Has the child had the food since with any reaction?

Food allergic reactions will tend to be consistent occurring on every exposure.

Does the child eat a regular portion of all foods?

Food avoidance may be a sign of food allergy.

Think food allergy in a child

– with faltering growth and one or more gastrointestinal symptoms. – with early onset severe atopic eczema. – where optimal treatment to date for eczema and the GIT has not responded.

Elimination needs to be carried out as part of an overall management plan and for a defined length of time. In all cases of cow’s milk exclusion and exclusion of more than one food the child should be referred to a Community or Paediatric Dietitian. The cornerstone of any elimination is the substitution or replacement with a suitable age appropriate nutritional equivalent otherwise growth faltering, rickets, nutritional compromise, food aversion and cross reactivity are potentially real consequences. Cow’s milk substitutes are a particular case in point: soy formula or goat’s milk are not always suitable because of the risk of cross reactivity. Rice, oat, almond or other plant derived milks are not always nutritionally suitable for children. If following diagnosis, long term dietary elimination of a food is indicated, then the issue of when and how to reintroduce it has to be addressed and should be included in the overall management plan. The natural history of food allergy appears to be changing – most children are expected to outgrow early food allergies by about age 8 but the only definitive way of knowing is by clinical re evaluation over a defined period of time. Medication There is no cure for food allergy but it can be managed. Medication will form part of a comprehensive agreed management plan. A non sedating antihistamine is indicated for managing mild to moderate allergic reactions. Following a comprehensive clinical history, examination and risk assessment it is usually clear if a child is at risk of an allergic reaction requiring the use of an age/weight appropriate adrenalin auto injector (AAI). International best practice guidelines describe in detail the rationale for prescribing and using AAIs.5 At the time of prescription those requiring AAIs must be given clear instruction on when and how to use them and these competencies should be reassessed on a regular basis. Management Take a focused history as described above.
Optimize treatment and assess compliance if there is existing eczema, asthma or rhinitis.
Refer to a local community/paediatric dietitian especially if cow’s milk or multiple foods are avoided. Assess the need for allergy medication.
Parents need a clear plan, includ14

Soy formula or goat’s milk are not always suitable because of the risk of cross reactivity. ing information for pre-school etc. that addresses all aspects of food allergy specific to the needs of their child.
If food allergy is suspected or if it’s unclear, NICE recommend assessment and management by a healthcare professional with the appropriate competencies. 3 Any practitioner who’s uncertain or unhappy with their level of competence should refer onwards. There are a number of paediatricians nationwide with specialist training or a special interest in food allergy:
Prof Jonathan Hourihane, CUH, Cork
Dr John Fitzsimons, OLOLH, Drogheda, Prof Alan Irvine, OLCH, Crumlin Dr Imelda Lambert, MRH, Mullingar Dr Edina Moylett, UCH, Galway. Food allergy mostly presents to a primary care setting in which there currently is no training or education for practitioners. The Irish Food Allergy Network was formed in October 2010 as a professional working group with a common interest in food allergy. Its Core Working Group is in the process of taking steps to address the service gaps that exist by producing diagnostic algorithms and care pathways for primary and secondary care; these are in draft form and hope to be finalized by year end. References 1. Sampson HA. Update on Food Allergy. J Allergy Clin Immunol 2004; 113(5): 805-819. 2. Leap. www.leapstudy.co.uk/amarch.html. 3. NICE food allergy in children and young people, February 2011 
http:// guidance.nice.org.uk/CG116 4. Fitzsimons J, Kieran E. Paediatric food allergies and intolerances. ICGP Forum Distance training 
module 166: June 2011. 5. Muraro A, et al. The management of anaphylaxis in childhood: position paper of the European 
academy of allergology and clinical immunology. Allergy 2007; 62: 857-871.