Future trends in Food Allergy
Academy for Paediatric Gastoenterology – March 2015
Cow's Milk Allergy – the complexities and the guidelines – Dr Trevor Brown
Future trends in Food Allergy for IgE and non-IgE – Dr Adam Fox
Hypo-allergenic formulae – Natalie Yerlett
Weaning your child: can we develop new guidance – Dr Rosan Meyer
FPIES: diagnosis and management – Louise Littler
Quality of Life in food allergy – Dr Rosan Meyer
Dr Trevor Brown, Consultant Pediatrician, Ulster Hospital, Belfast
Dr Brown is one of the UK's leading experts on cow's milk allergy (CMA) and has been intimately involved in the creation of the four guidelines that now exist for its management. He described some of the background and the difficulties in the area.
Cow's milk allergy is the most complex of the common food allergies. It normally involves other allergies and is, very often, non IgE mediated so very much harder to diagnose. Some figures:
2-4% of formula-fed UK infants are cow's milk allergic
There is a ten-fold discrepancy between parent-reported allergy and diagnosed allergy but that is mainly because non IgE CMA is not included in the diagnosed figures.
Figures from the 2010 UK GP's database suggest that 1% of infants are diagnosed by the age of three months but that it takes a further three months and 4.2 visits to the GP for the other 3-4% to be diagnosed.
86% of cow's milk allergic infants are diagnosed in primary care with 42% being referred on, although they may have to wait up to three months for a specialist appointment. Less than 10% of these families are referred to a dietitian.
Over 90% of these children have mild to moderate, non IgE cow's milk allergy.
There are now four diagnosis and management guidelines available:
2014 BSACI Cow's Milk Allergy – designed for specialist use.
2011, updated 2014, NICE Diagnosis and assessment of food allergy in children and young people in primary care and community settings.
2014 MAP Guideline - A primary care guide to the diagnosis and management of cow's milk allergy in the first year of life
Notes on the individual guidelines:
Severe forms of non IgE mediated cow's milk allergy
FPIES (Food protein-induced enterocolitis syndrome). See Louise Littler's presentation below but cow's milk is the commonest trigger for FPIES.
EGIDS (Eosinophilic Gastrointestinal Disorders). Management is usually a six food elimination although milk is by far the commonest trigger.
Dr Adam Fox, Consultant Paediatric Allergist, St Thomas' Hospital, London
A high proportion of children do achieve tolerance naturally. Figures from the USA in 2007 show that while 81% of a group of high risk children had Cow's Milk Allergy at 4 years this had reduced to 58% at 8, to 36% at 12 and to 21% at 16 years of age.
However, in 2007 treatment was, essentially, avoidance; in 2015 treatment is a balance between avoidance and measures to promote tolerance through active management:
1. Early introduction of the allergens –.
In a study at Mount Sinai School of Medicine in New York in 2008 75% of 2-17 year old children with mild to moderate cow's milk allergy could tolerate baked milk.
Oral and epicutaneous desensitisation
In management terms, its usefulness depends on whether the patient is more focused on safety or on normalisation of their life. This is probably dependent on the severity of their reactions. If safety, then it should then OIT should be avoided, if normalisation (so that they do not, for example, need to worry about 'may contain' labels) then it is a promising therapy.
Natalie Yerlett, Specialist Paediatric Dietitian, Great Ormond Street Hospital
In hypoallergenic formulae the protein structure is modified or broken down by heat treatment (hydrolysis) but it is not known where the breaks in the chain may come. In Extensively Hydrolysed Formulae (EHF) less than 1% of the protein remains and that is tolerated by 90% of CMA children. However, 30% of non-IgE cow's milk allergic children do not tolerate EHFs.
Dr Rosan Meyer, Principal Research Dietitian, Great Ormond Street Hospital, London
There is very little genuine agreement among health professionals as to the ideal time for weaning in the allergic child. Current guidelines are as follows:
One allergy, whether IgE mediated or not, suggests that the child may have others. Below are just some numbers from published studies, but these may vary depending on population and type of allergy:
The Infant Nutrition Survey in the UK indicates that normal weaning foods rely heavily rice porridge and often insufficient fruits and vegetables introductions. The most common food allergen in early infancy is cow’s milk. This increases the nutritional pressure to achieve nutrient intake as children that are weaned can not have cheese/yoghurt and other cow’s milk products. It is therefore important that the weaning diet is adequate to achieve normal growth and development.
When weaning atopic babies, start with low allergen foods and add new foods very gradually (one every 2–3 days) and one at a time but cumulative. Try a cooked version first and try them early in the day so you can monitor any reactions. Empower the parents to recognise reactions and to deal with them.
Guidelines badly needed!
Louise Littler of FPIESUK.org
FPIES (Food Protein-Induced Entercolitis Syndrome) is the most severe form fn non-IgE mediated food allergy. It usually occurs in children under 12 and is often misdiagnosed.
It causes profuse vomiting and lethargy 1–6 hours after the ingestion of the food. In 20% of cases the child MAY also go blue and suffer from hypotension (low blood pressure). The blue tinge may last for up to two weeks. 25% of children may also have diarrhoea. It is not fatal but very scary.
Because it also causes a dramatic increase in neutrophils it is often misdiagnosed as sepsis and sometimes as viral gastroenteritis. (In the FPIES group 25 families had 58 emergency admissions to hospital without a single correct diagnosis. Consultants are unwilling to diagnose while most dietitians are unaware of the condition.)
The only current treatment is the replacement of fluids although anti-emetics seem to be helpful. Provided fluids are replaced the child will recover in 2–3 days, otherwise it may take 2–3 weeks.
Because of the violence of the reaction, FPIES has a dramatic effect on the families' quality of life and can have behavioural effects on the children.
FPIES can be to any foods but is usually to the first weaning foods: milk, soya, poultry, rice, oats, legumes, bananas, sweet potatoes, egg. It is rarely to more than two foods (although often in the same food families) and it often occurs along with other allergies. There appears to be a genetic element in FPIES but the only tests are the normal food challenge tests.
FPIES children usually do well on Amino Acid formula, in a few cases it may not be tolerated. However for those children who do have symptoms on an elemental, amino acid formula: consider it may not be FPIES, it could be other sources of allergens in toothpaste, drugs or in some other disguised form or another medical condition alongside FPIES, Eosinophilic gastroinstestinal Disease for example. And although in FPIES diarrhoea can go along with vomiting, if it is diarrhoea alone, it is not FPIES.
The condition urgently needs more recognition – and a more user-friendly name! – as well as some FPIES specific tests.
FPIES is to non-IgE food allergy what anaphylaxis is to IgE food allergy – the most extreme form of the condition.
Dr Rosan Meyer, Principal Research Dietitian, Great Ormond Street Hospital, London
There are no validated tools with which to assess Quality of Life (QOL) for non IgE food allergy, but there are very good validated tools for for IgE. However, QOL for peanut allergy sufferers compares poorly with QOL of sufferers of rheumatoid arthritis, diabetes and cystic fibrosis. The disruption and anxiety, especially among parents is higher than in other conditions although the children tend to cope relatively well.
In a recent unpublished study carried out at GOSH, the QOLs was worse in children with non-IgE mediated allergy than a matched control group with sickle cell anaemia. The group also found that although the total score for QoL was lower than children with gut failure (short bowel syndrome) this did not reach statistical significance for all categories.