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

Lanarkshire database �  N=518

0 10 20 30 40 50 60 70 80 90 100

Egg

Peanut

Nut

Milk

Pulse

Lentil

Sesame

Fish

Cashew

Strawberry

Wheat

Kiwi

Tomato

Soya

Prawn

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

Allergy? �  Eczema

�  Cough

�  Throat “closing over”

�  Grunting

�  Fainting

�  Diarrhoea

�  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

Know your dietician!

Avoidance �  Food knowledge?

�  Labels, shopping

�  Eating out

�  Parties

�  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 2nd year, 66% become tolerant by age 5yr

�  Peanut allergy persists throughout adulthood in 80%

School �  Emergency allergy plan

�  Teacher awareness

�  Peer awareness

�  Catering awareness

�  Exclusion, bullying

�  School trips

Challenge �  At home or in hospital?

�  What with?

�  When and where?

�  Written plan?

�  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