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Clinical Manifestations and Management of Food Allergy
Adrian Sie
Consultant in paediatrics, Wishaw General, Lanarkshire
April 2013
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To do � Bring Allergy plan
� Prevention photo
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Contents � Is it allergy?
� How do I prevent anaphylaxis (should they get an Epipen)?
� What follow up?
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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
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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
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Lanarkshire database � N=518
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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
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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
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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
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Diagnosis? � Reaction to naan bread
� Reaction to hummus [known peanut allergy]
� Reaction to Aldi waffle [known lentil allergy]
� Reaction to pizza
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Symptoms and Signs � Skin
� Tongue/lips
� Nose
� Eye
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Allergy? � Eczema
� Cough
� Throat “closing over”
� Grunting
� Fainting
� Diarrhoea
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� Nice type 1 chart
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Not Allergy? � I’m allergic to that
� Idiopathic urticaria/angioedema
� I hate that
� Chemical
� GORD, infantile colic, constipation, nappy rash
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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
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Anaphylaxis? cont � Acute onset, skin/mucosal involvement, plus
respiratory or cardiovascular compromise (egbronchospasm) [EAACI position paper 2007]
� How would you manage?
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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
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Would you test? 1 � 10yr old, known peanut allergy, no reactions for
years
� Yes, but unlikely to change over 12yrs
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Would you test? 2 � 2yr old, obvious reaction to first taste of nuts
(peanut butter)
� Helps prognosis
� Other nuts
� Co-sensitivities
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Would you test? 3 � 3yr old, previous egg allergy as baby, now eating
hidden egg � No, unless high risk
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Diagnostic accuracy please! � Nut allergy vs Peanut allergy
� Peanut anaphylaxis
� Possible peanut allergy (SPT neg)
� Possible peanut allergy (IgE pos)
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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
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Know your dietician!
Avoidance � Food knowledge?
� Labels, shopping
� Eating out
� Parties
� Grandparents
� Alternatives, nutrition
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Traces � May contain traces of peanut
� Made in a factory where nuts are used
� Most families allow at least familiar foods
� Risk assessment approach
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All nuts? � Tree nuts?
� Coconut?
� Seeds?
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Management of Allergic Reaction
� Scenario
� Recognize mild vs severe symptoms?
� Use of antihistamine?
� Poor response?
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Management of Anaphylaxis
� Pen carried? How many? In date?
� Indications for pen
� Use of pen
� Use of other medicines
� Wait on ambulance
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Other issues � Asthma, hay fever etc
� High risk? Epipen? Medicalert?
� Cross-sensitivity
� School/nursery
� Holidays
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Other issues cont � Prognosis? Challenge?
� Transition
� Patient support groups � Allergy UK � Anaphylaxis Campaign
� CYANS
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High risk kids � Lots of allergies esp nuts, esp peanut
� Reaction with trace exposure
� Previous anaphylaxis
� High test result
� Poor asthma control
� Teenagers
� Remote
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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
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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
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� Epipen quiz/video
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Co-sensitivity � Nuts
� Pulses
� Fish
� Fruit/Veg/Latex
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Will it get better? � Depends on the allergy
� Depends on the age
� Depends on the test result
� Depends on desensitization – can recur!
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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%
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School � Emergency allergy plan
� Teacher awareness
� Peer awareness
� Catering awareness
� Exclusion, bullying
� School trips
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Challenge � At home or in hospital?
� What with?
� When and where?
� Written plan?
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� Egg challenge clip
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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
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Support � CYANS
� Allergy UK
� Anaphylaxis Campaign
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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
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Eczema � NICE guideline
� Significant eczema with multiple suspected food allergies
� Moderate to severe eczema in infants
� Type 1 reactions
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Egg allergy � Raw (meringue) vs sloppy (scrambled) vs cooked
(cake)
� MMR?
� Flu vaccine?
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Idiopathic Urticaria � Urticaria/angioedema
� Prolonged
� No clear trigger
� Recurrent?
� Rx Antihistamines
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Chemical � Salicylates
� Amines
� Benzoates
� Sulphites
� Histamine/Scombroid
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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
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Summary � Increasing problem
� Prevention difficult
� History, history, history
� Not all “allergy” is allergy…
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Summary cont � What can we do better?
� Diagnosis
� Co-sensitivities � Information: allergy plan, challenges
� Epipen support � Hay fever, asthma � Prognosis, incl risk
� Transition