This was the first Allergy Academy study designed for non-healthcare professionals – more specifically for parents, families, teachers, nurses and carers working with allergy and, in particular, with allergic children. It covered the three main stages of the 'allergic march' – eczema, food allergy and asthma/respiratory allergy.
The day was introduced by Dr Leanne Goh, a King's College Allergy Academy Fellow, who had also pulled the programme together.
Having traced allergy back to Mens, the first Pharoah of Egypt, who is thought to have died of an allergic reaction to a wasp sting, she emphasised the difference between immediate response and delayed response allergy, the former being relatively easy to diagnose, the latter, much harder. She also pointed out how infantile eczema frequently led to toddler/young child food allergy and then on to teenage asthma, hay fever and rhinitis – the allergic march.
Allergy is now the commonest childhood disease with up to 40% of children having asthma and one in seventy having a nut allergy; this is the more concerning as their allergy impacts on every aspect of their lives.
But despite the fact that attending an allergy clinic significantly improves the general control and well being of an allergic child, the UK still falls far behind other European countries in their provision for allergy. In the UK there are around 15 dedicated allergists (as opposed to organ-based allergists) to care for a population of 60–70 million; in Germany (population 80 million) there are 50; in Denmark (population 2 million) there are 50 and in Finland (population 5 million) there are 100.
Dr Goh also quoted a study by Dr Richard Pumphrey which found that of the 48 allergy related fatalities that occurred between 1999 and 2006, not one had been assessed in an allergy clinic.
Adverse reactions to food
Dr Adam Fox, Consultant in Paediatric Allergy at St Thomas' Hospital and Director of the Allergy Academy.
Dr Fox also emphasised that the UK was the most allergic country in the world, although there had been a rapid and alarming growth in the incidence of allergy over the last ten years in South East Asia and South America, parts of the world which had been relatively allergy free.
He too emphasised the importance of distinguishing between immune related, immediate allergy and delayed response intolerance. The former is easy to diagnose as there is nothing else like it; the latter far harder as the symptoms are shared with many other conditions, there are no effective tests and there is no real understanding of the mechanisms.
He illustrated the difference by looking at cow's milk allergy which falls into three groups:
1. A very tiny amount of milk will cause a very speedy reaction. Blood tests will show an allergy. (In this case mast cells, triggered by the allergen, release histamine which causes the allergic reaction.)
2. A larger amount of milk (but not a huge amount) will trigger reactions such as an eczema flare up over 2–6 hours. Blood tests will show very little.
3. Cumulatively, a large volume of milk over several days will trigger reactions but all blood tests will be negative.
Moreover, reaction may depend on the processing of the allergen (the protein). eg. 80% of those who are allergic to raw egg can tolerate cooked egg.
Eczema and food allergy
There is a very important association between eczema in the first year of life and food allergy; this increases with the severity of the eczema (70% of infants with serious eczema will have a food allergy) and with the age that the eczema started (the younger, the higher the likelihood).
The symptoms of food allergy are very obvious: immediate (and reproducible) urticaria, hives, swelling, itchiness. However, fully blown anaphylaxis (a dramatic drop in blood pressure) is very rare in small children.
Common 'allergic' foods
The foods most frequently implicated tend to be directly related to the local diet so that in the UK and the West it is milk and eggs, in India it is gram flour, in Spain peach, in Indonesia, birds' nest.
Tests and diagnosis
Skinprick tests are not helpful for diagnosis as they give too many false positives (the child tests positive for an allergen to which they may be sensitised but to which they do not react), although they can be helpful for confirming a suspected allergy.
The gold standard for diagnosis of food allergy is a food challenge but this is expensive in doctor/nurse time – and the child will not always comply! Especially if it has had a bad reaction previously.
Quality of life
A diagnosis of food allergy can have a massive effect on the quality of life of both the child and its family – higher than a diagnosis of diabetes – as it brings with it concerns about nutrition, feeding behaviours and the possibility of a fatal reaction. However, families should remember that most fatalities occur in teenagers who also have badly controlled asthma and that the risk is still immensely much lower than the risk of dying in a car accident.
The aim is to get parents to be 'sensible' – to make a balanced risk assessment and to take reasonable precautions without becoming obsessive. But it is important that they are aware of the nutritional risks of restricting the diet; there is, for example, a marked increase the the incidence of rickets amongst children attending allergy clinics as a result of vitamin deficiencies. It is therefore important to review the diet by challenge (but only under medical supervision) on a regular basis so as not to restrict it unnecessarily.
Finally, the New NICE guidelines - Food Allergy in Children and Young People, are very helpful.
Food Allergy in Practice
Tanya Wright, paediatric allergy dietitian, St Thomas' Hospital
(Also author of the excellent 'I'm Hungry... Easy family recipes free from milk, egg, soya, wheat & gluten'.)
Management of food allergy falls into four areas:
• What to know
• What to avoid
• How to avoid it
• How to replace it
What to know
Getting a diagnosis of food allergy is relatively easy; getting a diagnosis of hidden or delayed food sensitivity is more difficult.
• Keep a detailed food and symptom diary.
• Take any useful tests that may be available – but 'useful' tests do not include IgG tests which will not tell you anything useful
• Exclusion and challenge (excluding the food for several weeks to see if symptoms improve then trying it again and seeing if symptoms worsen) is the only reliable way to diagnose a hidden food sensitivity.
• Once the problem food is identified it needs to be avoided – see below.
• Even if the food is avoided, there may still be symptoms. In which case a more detailed diary is needed. If possible a photo of the reaction and of the food/packaging of the food that is thought have caused the reaction is very helpful in diagnosis.
How much to avoid
It is important not to restrict unnecessarily so it is important to know whether the food needs to be avoided completely or just its consumption reduced. Similarly, whether the food can be eaten safely cooked (eggs or milk) but not raw. But this means that you need to know, for example, that cake icing uses raw egg whereas the cake itself uses cooked egg.
If the food needs to be avoided completely, then you need to be aware of contamination issues – the same utensil (knife, spoon, chopping board, drying up cloths) must not be used making egg/milk/nut-free food as for 'ordinary' food.
If the food needs to be avoided completely you also need to be aware of personal contact; if it is a small child no one who touches the child (parents, carers, friends, other children) must have touched the allergen as it can be easily transmitted to the allergic child.
Similarly, you will need to check vitamin pills and drugs and household cleaners for traces of allergen – Abicdec child vitamin pills, for example, contain refined peanut oil, Ecover washing up liquid includes a milk protein.
Finding safe foods
Shopping will become a lot tricker as every label needs to be checked.
• So many brands have both an allergen free and a non-allergen free version of the same product so you need to check which one you are buying viz: Birds custard, Heinz soups, Walkers Crisps.
• Products may have a totally unexpected allergen - a pea protein in chicken...
• Formulations of products may change to include an unexpected allergen without it being flagged up on the pack
• Always double check the labels every time you shop.
Ensuring the allergic person still eats and tasty nutritious food
• Check up on standard products – they may already be allergen free and fine.
• Check labels on freefrom products to make sure that they are OK for you.
• Adapt family recipes to exclude the allergen.
• Try alternative grains, non-dairy milks, yogurts etc.
• Use apps such as FoodWiz to help you shop.
• Plan ahead, especially snacks.
• Bulk cook and freeze, but remember to label carefully.
• Use convenience foods wherever you can.
• Always have a contingency plan....
Getting the nutrition
Provided you are sensible, this will not be a problem. However, to be on the safe side you may wish to also supplement.
• It is very important that you tell everyone about your own or your child's allergy and how a reaction should be dealt with e.g. family, friends, teachers etc
• Apart from telling them about the allergy you can get jewelry, badges, lunch boxes, T-shirts and bibs all of which warn about the allergy.
• Translation cards are invaluable for travelling – but always take emergency supplies.
Carry your medication(Epipen) with you at all times. Up to 25% of those diagnosed with a potentially fatal allergy do not carry their emergency medication.
Many food allergies, especially those in young children, resolve (they may become less sensitive to egg or milk for example, and the child may be able to tolerate the allergen cooked even if they still cannot tolerate them raw). So it is important to reassess your own or your child's allergies regularly so as to avoid unnecessary food restrictions. However, this must only be done under medical supervision.
Sniffing and Sneezing – is it an allergy?
Dr Sophie Faroque, consultant at St Mary's Hospital, London
Rhinitis is a nasal inflammation that causes an itchy, runny, dripping, blocked nose; it also causes snoring, a mucous drip down the throat and is often related to hyperactivity. There can be many causes but allergic rhinitis is the predominant form in children although only in around one third of adults. There has been a significant increase in rhinitis over the last 30 years and there is a strong link between allergic rhinitis and asthma.
Most common causes
• tree pollen
• house dust mite faeces
• animal dander
• food sometimes, although not as often as is sufferers may feel that it does
• hay does not cause rhinitis
• flowers with small, heavy pollen distributed by birds and bees does not cause allergic rhinitis
• grasses and trees whose pollen is distributed by the wind, does cause allergic rhinitis
Airborne allergens and irritants cause a release of histamine in the nasal passages, which, in turn, causes inflammation and fluid production in the nasal passages, the sinuses and the eyelids.
Skin prick tests, in the context of the patient's history, can be a very useful way of diagnosing the allergy and pinpointing the allergen.
Why would one treat rhinitis?
• it significantly affects patients' quality of life
• untreated, it leads to significant complications:
– sleep disturbance
– glue ear
– asthma – asthma and rhinitis need to be treated as two sides of one condition, not separately
• untreated, rhinitis can impact seriously on daily life
– schooling (GCSE exams all coincide with the peak of the pollen season and the 43% of adolescents who suffer from allergic rhinitis will drop a grade if they take their exams in the pollen season)
• surgery (very rarely)
What changes are you prepared to make?
• Pets. Animal dander is a major allergen and there is really no such thing as a hypo-allergenic dog or cat. Cat allergens are particularly sticky and it can take up to four years for allergen levels to fall in a house where there has been a cat unless there is a major and deep clean.
If you cannot bear to get rid of the animal then keep it out of the bedroom
and deep clean the bedroom.
• Dust mite. There is no way of completely eliminating dust mites. But you must be thorough as half measures in terms of elimination will not help. However, be sure that it is house dust mite that is the problem before cleaning – skin prick tests will identify the allergen.
– remove carpets or damp clean
– replace curtains with blinds of shutters
– reduce humidity in the room
– cover mattresses, pillows and bedding with mite proof covers
– remove soft toys and cushions
– hot wash toys to kill the mites (NB. Freezing the toys will kill the mites but not remove the faeces which are the allergic element)
• Avoiding pollen
– wear sunglasses
– do not mow grass or be near grass when it is being mowed
– plant a low allergen garden
– remove allergenic trees, such as birch, from your garden if you can
– keep windows closed when there is a high pollen count
– holiday by the sea or out of the pollen season it in the country
– avoid going out in the wind
– shower as soon as you come in from the garden
– use nasal filters – they are surprisingly successful in keeping pollen out of the nasal passages
– antihistamines – quick and flexible although can make you drowsy. (Piriton is particularly drowsy making.) Good as eye drops.
– steroid nose sprays decrease the inflammation in the nose but need to be used correctly, prophylactically and regularly. They take time to work but are the most effective control measure in the long term. However, they must be used properly to be effective. See below.
– decongestants provide instant relief but after a few days of use you get 'rebound' making the original condition worse
– immunotherapy – it can only be used for those with one or two inhaled allergens (not for asthma) but it can be effective and can delay the onset of asthma in children
– steroids. While nasal steroids are effective and have very few side effects, taking steroids orally, especially over a long period, may impact on a child's growth.
• Using nasal steroid sprays
– make sure you start at least 4 weeks before the pollen season starts
– wash the nose out with salt water before applying the spray
– do not sniff it back or tilt back the head so that the spray runs down the back of the throat
– the spray needs to stay in the nose
– if it feels as though it is running out, wash you teeth!! It will help the spray to stay in place!
– nasal sprays will also help runny and itchy eyes
• Take home message – be proactive – treat your rhinitis – it is easy to treat and will make a huge difference to your quality of life.
Is my eczema caused by an allergy?
Dr Claudia Gore, consultant Paediatric allergist, St Mary's Hospital
Normal skin is like a brick wall – an intact barrier against anything on the outside which also hold moisture in the skin.
In eczema that barrier is disrupted – the bricks are not stacked properly or the mortar has fallen out so that moisture escapes (the skin dries out) and infection can get in.
This causes inflammation which, in turn, causes pruritus or itching, which causes the sufferer to scratch the itch. This increases the inflammation and itching which can often break the skin allowing infection to penetrate – such as staphylococcus aureus which most people carry on their skin. This can cause an allergic reaction itself and also allows easier access to other allergens through the broken skin.
Incidence of eczema in children has continued to increase over last 30 years:
1973 – affected approximately 5% of children
1988 – affected approximately 15% of children
2003 – affected approximately 25% of children
What to look for
• erythema – redness or darker skin colour
• papulation or bubbly skin
• oedema or swelling
• oozing, crusting
• lichenification or thickening of the skin
• excoriation or scratching
Quality of life
The QOL of 98% of infants (3–6 months) is significantly impaired by eczema.
• They do not sleep well, they are unhappy, itchy.
• They cannot play properly, cannot go swimming, cannot take part in many family activities.
• Treatment – bathing, moisturising etc – takes a lot of time and impacts seriously on family life.
• Although many parents (33%) believe that eczema is caused by food allergy, it rarely is (only 8% of cases). However, food allergy certainly does exacerbate eczema.
• Although there is often a connection with cow's milk allergy it is not clear whether the eczema pre or post dates the CMA.
• It is important to focus on IgE mediated, immediate reaction, food allergy; the most common foods implicated are milk and egg, followed by soy and wheat.
• If the eczema starts when the child is under two year of age, and especially if is starts very early (under 3 months) it is important to test for food allergy.
• Infants with eczema frequently also suffer from reflux, gastroenterological problems, rhinitis, asthma and conjunctivitis.
• If specific food is to be excluded, the skin needs to be clear before you start, otherwise you will not get a clear understanding of what is causing the eczema, and the exclusion needs to be for 4–6 weeks before challenge.
• Only try one treatment at a time (food exclusion, new medication etc) otherwise you will never know which ones do/do not work.
What parents want to know
What caused the eczema – genetic background or environmental problems.
The ItchySneezyWheezy website very helpful.
Keeping the skin moist is the most important element of treatment so constant application of creams/emollients is vital.
• Cream should always applied very generously with the whole hand in the direction of the hair. If you rub cream into the skin against the hair you risk rubbing it into the hair follicles and blocking them.
• Use a clean spoon to take creams out of the pot so as not to contaminate them.
• If you are using steroids they should be applied, after the emollient, with the tip of the finger specifically where they are needed, not rubbed all over. Using lots of emollient will reduce the need for steroids.
• Eczematous skin is very temperature sensitive so be careful only to use cool/luke warm water – not either very hot or cold.
• Do not use food based creams or oils as sensitisation can happen via the skin.
• Pre-moisturise before a bath or shower, especially if the eczema is bad.
• Only wash with the hands, do not use cloths or sponges which will be harsh on damaged skin.
• Bathe daily or two or three times per day if the eczema is bad.
• Take care with babies as their skin will be oily/greasy and it will be easy to let them slip!
• If school age, re pot the creams into fun pots so that they will not mind remoisturising during the day.
• Dermovate – super-strong steroid cream – do not use on the face or on babies.
• 1% hydrocortisone – mild and suitable for use on any part of the body and on babies.
• Any other steroid creams, check with your doctor/consultant/on line before using.
• Apply in finger tip units and smooth in the direction of the hair.
• Prescriptions often too mean; ask for double prescription.
• Skin thinning only occurs if the cream is strong and if it is used for a long time.
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