Food Allergy (under 18) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • IgE and non IgE mediated food allergies in children under 18

This guidance does not cover:

  • Other atopic or non allergy related conditions

Assessment

Signs and Symptoms

The most common foods causing allergies in children are:

  • Milk, egg, peanut, tree nuts, soya, fish, shellfish, wheat and kiwi fruit
  • IgE mediated reactions occur quickly within 2 hours and are acute.
  • Non IgE mediated symptoms can be much more delayed.
  • NICE lists the following symptoms:
The skin
IgE-mediatedNon-IgE-mediated
PruritusPruritus
ErythemaErythema
Acute urticaria – localised or generalisedAtopic eczema
Acute angioedema – most commonly of the lips,
face and around the eyes
The gastrointestinal system
IgE-mediatedNon-IgE-mediated
Angioedema of the lips, tongue and palate
Gastro-oesophageal reflux disease
Oral pruritusLoose or frequent stools
NauseaBlood and/or mucus in stools
Colicky abdominal painAbdominal pain
VomitingInfantile colic
DiarrhoeaFood 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)
The respiratory system
(usually in combination with one or more of the above symptoms and signs)
IgE-mediatedNon-IgE-mediated
Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea or congestion [with or without conjunctivitis])
Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)
Other
IgE-mediatedNon-IgE-mediated
Signs or symptoms of anaphylaxis or other systemic allergic reactions

A history of anaphylaxis (airway or circulatory compromise, unstoppable vomiting) should trigger a referral to the allergy clinic.

History and Examination

Focussed history:
  • the age of the child or young person when symptoms first started
  • speed of onset following food contact
  • duration of symptoms
  • severity of reaction
  • frequency
  • setting of reaction (for example, at school or home)
  • reproducibility on repeated exposure
  • what food and how much exposure causes a reaction
Clinicians should directly ask about:
  • Asthma
  • Eczema
  • Hayfever
  • Family history of atopy
Examination should pay particular attention to:
  • growth and physical signs of malnutrition
  • signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic rhinitis).
Differential Diagnoses
  • Hereditary angioedema or spontaneous urticaria
  • Concurrent viral infection
  • Drug allergy
  • Erythema migrans or other childhood rashes
  • Gastroenteritis

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Faltering growth
  • Multiple food allergies causing moderate or severe dietary restriction
  • Blood in stool causing haematological changes
  • Unusual history or concern about history

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Specific IgE blood tests can be performed to single allergens if there is a clear history.
  • Avoid a scatter gun approach with panels of tests being performed.
  • Alternative testing such as kinesiology, hair analysis, IgG or Vega testing are not recommended.
  • Skin prick testing if facilities are available, or can sometimes be arranged in the allergy clinic.

Management

IgE mediated
  • Proven reactions to food should lead to avoidance of that food, with appropriate follow up to assess tolerance as the patient grows.
  • Guidance from the RCPCH advocates the provision of emergency plans which can be downloaded here
Non-IgE-mediated food allergy
  • Trial elimination of the suspected allergen (normally for between 2–6 weeks) is recommended.
  • It is extremely important to offer a 'reintroduction' after the initial trial, to test reproducibility of the reaction.
  • Seek advice from a dietician with appropriate competencies about nutritional adequacies, timing of elimination and reintroduction, and follow-up.

Cow's milk allergy is common.

Egg is the most common allergy in small children. It can present as an IgE mediated or non IgE mediated reaction. Baked egg is less allergenic and some will tolerate baked egg much earlier, or from the start of their allergy. A copy of the BSACI "egg ladder" can be found on page 1121 of this paper.

  • The MMR vaccine does not contain egg and can be freely given in primary care to egg allergic patients
  • The green book chapter 19 now has up to date guidance on influenza vaccinations and egg allergy. Further information can be found from BASCI here. Essentially, only if the patient has a history of anaphylaxis to egg do special considerations need to be applied for vaccination.
  • Please take special note of children with moderate to severe eczema and/or egg allergy; new evidence found in the LEAP study suggests they should be referred to paediatric allergy between the ages of 4-11 months for early introduction of peanut to prevent peanut allergy, this should not be done at home, however specialist input is required as rapidly as possible.

Referral

Referral Criteria

As per the NICE guidelines please refer if there are any of the following criteria:

  • faltering growth in combination with one or more of the gastrointestinal symptoms described above
  • lack of response to a single-allergen elimination diet
  • one or more acute systemic reaction or severe delayed reaction
  • confirmed IgE-mediated food allergy with concurrent asthma
  • significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer
  • persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms) despite a lack of supporting history
  • strong clinical suspicion of IgE-mediated food allergy but allergy test results are negative
  • clinical suspicion of multiple food allergies
  • moderate to severe eczema in an infant with egg allergy

Referral Instructions

  • e-Consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals to the Paediatric Allergy Clinic should be made via eRS
  • Please identify speciality and clinic type
  • Urgent referrals should be made to the children's assessment unit (CAU)

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 03.2019
  • Ref No: AL4 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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