1. Paediatric Allergy in West Essex
Sue Clarke, Dr Liz Owen and Dr Neha Khanna

2. Learning Outcomes
Appreciate the differences between IgE mediated and non IgE mediated reactions
Understand the importance of taking an allergy focussed clinical history to form a diagnosis
Appreciating when infants need referral and when they can be managed in Primary care
Update on West Essex Services and from April 2017
Secondary care in West Essex: testing, treating and other allergies

3. IgE mediated allergy

4. Non IgE mediated

5. Non IgE mediated

6. Gastro-intestinal symptoms 50-60%
IgE
Non IgE
Angioedema of lips, tongue and palate
Oral pruritis
Nausea
Colicky abdominal pain
Vomiting
Diarrhoea
Gastro-oesophageal reflux
Loose or frequent stools
Blood or mucus in stools
Abdominal pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor and tiredness
Faltering growth with one or more GI symptoms or significant atopic eczema

7. Skin symptoms 50-60% IgE Non-IgE Rapid onset Pruritis Erythema
Acute urticaria
Angioedema
Delayed onset
Pruritis
Erythema
Atopic eczema

8. Respiratory symptoms 20-30%
IgE
Non IgE
Nasal itching, sneezing, rhinorrhoea or congestion (with or without conjunctivitis)
Cough, chest tightness, wheeze and shortness of breath
Anaphylaxis and systemic allergic reactions
Cough, chest tightness, wheeze and shortness of breathe
Congestion, catarral.

9. Assessment and allergy-focused clinical history
Consider the possibility of food allergy when symptoms of atopic eczema, gastro-oesophageal reflux disease or chronic gastrointestinal symptoms do not respond adequately to treatment
If food allergy is suspected, a healthcare professional should take an allergy-focused clinical history, and physically examine the child based on the findings. (NICE CG116, 2011)

10. Allergy focussed clinical
Past medical history?
Family history?
Timing of the symptoms – immediate or delayed?
What symptoms experienced?
What quantity consumed?
Physical examination

11. Objective testing for IgE mediated allergy
Skin prick testing
Specific IgE mediated serum testing

12. Testing for Non-IgE mediated allergy
Patch testing?
Elimination diet?
Vega testing?
Applied kinesiology?
Hair analysis?
IgG testing?

13. Management - MAP guidelines
Milk Allergy in Primary care
Guidelines help to guide management

14. Management of IgE mediated allergy
Allergy clinic referral
Allergen avoidance
Risk assessment for future reactions
Emergency treatment for accidental exposure-AAI
Training package
On going education and support

15. Management of Non IgE mediated allergy
Trial elimination diet for 2-6 weeks, then challenge
Extensive education about avoidance
Avoidance advice for breastfeeding mothers
Hypoallergenic formulas
Referral to dietitian

16. Specialist formulas
Breastfeeding is the preferred way to feed an allergic baby
Partially hydrolysed
Extensively hydrolysed
Amino acid formulas
Soya
Lactose free

17. What baby milk?

18. Case studies

19. Emily 1
5 month old with persistent colic, gastro-eosophageal reflux and constipation
Taking Gaviscon and Lactulose daily.
Normal weight gain (on 75th percentile)
Has been on cow’s milk formula from birth

20. Emily 2
Mum suspects cows milk allergy, she’s keen to try goats milk to see if this would help?
Father had a milk allergy as a baby, now hayfever
Examination showed mild eczema and dry skin
No immediate type symptoms

21. Emily 3 ?Non IgE mediated CMPA How would you proceed? Goats milk?
Soya milk?
EHF Formula
AA formula
Lactulose/Gaviscon?

22. Emily 4
Commenced on eHF
Mum started weaning, advised dairy free. (Dietetic referral)
Within 4 weeks symptoms much better. Challenge confirmed diagnosis.
Continued on an extensively hydrolysed formula until 12 months when tolerated cow’s milk without symptoms.

23. Henry 1 Henry is 4 months old.
He‘s exclusively breastfed, but dropping through the centiles from 50th to 9th.
He has excessive colic, abdominal pain, severe congestion and reflux.
He cries for long periods and Mum has noticed mucus in his stools

24. Henry 2
Mum had a milk allergy when she was a child and Dad has eczema. Mum keen to try a dairy free diet. How would you advise her?

25. Henry 3 Advice on strict exclusion for up to 6 weeks.
Maternal supplements of calcium and vitamin D.
Rapid improvement in Henry’s symptoms. Mum maintained dairy free diet until 12 months old when Henry tolerated milk in his diet

26. Matthew 1
13 month old baby with moderate to severe eczema since 2 months of age.
Recently developed wheezy episode with a cold virus.
Coughing at night
Acute urticaria, lip swelling and projectile vomiting after cow’s milk. Tolerating formula.

27. Matthew 2
Matthew is very miserable with eczema and requiring frequent ABs for recurrent infections
FH of allergy- Dad hay fever, cousin has peanut allergy
Becoming a very fussy eater.

28. Matthew 3 SIgE testing shows ++ to milk.
How would you manage Matthew now?
In Primary care?
Treatment options?

29. Matthew 4 Specialist allergy clinic Allergen avoidance advice
Management plan
Adrenaline injector?
Allergy education
Dietetic advice
Support groups

30. Grace 1
Grace is 11 weeks old. She has severe colic, reflux and constipation from 2 weeks old.
Commenced on Similac Alimentum at 4 weeks and improved.

31. Grace 2
Some of Grace’s gastro-intestinal symptoms improved but she developed eczema and a very sore bottom.
Eczema failed to respond to emollients and hydrocortisone.
Sore bottom was raw and not responding to any creams

32. Grace 3
Grace was referred to a Paediatric allergist who prescribed an amino acid based formula.
Skin and sore bottom improved within a week.
Referred to a dietitian
Remained on AA formula until 12 months.
Audit at 12 months showed Grace eating cheese and yoghurts. Milk challenge tolerated and started on Cow’s milk.

33. Resources MAP Guidelines http://www.ctajournal.com/content/3/1/23
NICE CG116
RCPCH Care pathways for children with allergic conditions.

34. GP perspective
Dr Liz Owen GP

35. Reflux and CMPA
Feeding difficulties make a high proportion of GP time/appointments
Frequently accompanied by repeat visits to A+E as well as GP and HV
Parents and families in distress with constantly crying baby
Traditionally symptoms of pain and vomiting addressed as GOR to varying degrees of intervention
CMPA as a cause for the symptoms fairly new concept
CMPA an expensive condition to treat
Not short appointments due to level of distress often felt
Many practice top 5 or even top 3 of prescribing budgets – food and nutritional substances
So want to get the right children on the right treatment as soon as necessary

36. Flow chart introduced
To try to distinguish the children with GOR and those with GOR caused by milk allergy
40% with GOR will have CMPA as a cause
Get them on the right treatment and resolve symptoms asap
MAP guidance consulted and attempted to condense
Adaptation of previous document from medicine’s management
Explaining the roles of the HV and the GP
MAP can be a little hard to follow

37. Allergy focused history using the case finding tool
Complicated
Immediate onset symptoms (within minutes of ingesting milk – possible IgE mediated) of itch, rash, flare of eczema, diarrhoea, colic, rhinitis or conjunctivitis
One or more of:
Colic
Reflux
Feed refusal or aversion
Loose offensive stools
Perianal redness
Constipation
Abdominal discomfort
Blood or mucus in stools when otherwise well
Significant eczema
Uncomplicated (common)
Vomiting after feeds and showing discomfort
Reassurance and practical advice:
Avoid over feeding
Burp before, during and after feeds
Keep upright for 30min after feeding
Avoid tight nappies and clothing
Avoid laying flat – tip the cot, nappy changing etc
Avoid exposure to smoke (irritant)
Improvement?
Continue for 3 months or until weaning
Consider feed thickener eg carobel or comfort/anti-reflux formula (OTC)
2 week trial
GP assessment

38. GP assessment
Cow’s milk free diet – exclude from maternal diet if breast feeding, trial of EHF (similac alimentum) if not
NB for mixed feeding babies. if child having symptoms on breast milk top ups should be with AA formula
yes
Review ranitidine and omeprazole every 2 months, adjust dose to increasing weight, code GORD
Check for history consistent with IgE mediated response to milk or severe ‘non upper GI symptoms’ no
With symptoms recurring revert to milk free diet and continue until 9-12 months of age or at least 6 months.
<6 months 13 tins per month prescription
>6months 7-13 per month
Maternal supplementation of calcium (1g)and vit D (10mcg)
Important to exclude milk products from weaning foods
Keep milk the same – add ranitidine 1- 3mg/kg.
If severe symptoms or faltering growth trial omeprazole (dissolvable) to replace ranitidine
If no improvement in reflux consider CMPA and advise exclusion of dairy from maternal diet if breast feeding or 2-4 week trial of EHF if not (AA if top up to maternal diet exclusion
40% of children with moderate GORD have CMPA
Still no improvement, trial of AA formula and referral to paediatric allergy clinic
When there is improvement retrial is important for diagnosis:
Mother to add back in dairy to diet for 1 week or retrial of previous cow’s milk containing formula
Where symptoms do not return with reintroduction – not CMPA
Introduce concept of the milk ladder and consider for home trial or with dietician support as needed

39. Case finding tool for HV
Condensed form of focused allergy history
To be conducted with a health professional – ideally the health visitor for the child
Main point to decrease history taking time
From these descriptions should be able to distinguish IgE symptoms from non-IgE and likelihood of CMPA

40. What to do when presented with the info/case finding tool
Long winded guidance for GPs available
Salient points:
‘Stay down’ milks can be brought and very similar cost to normal so should ideally not be prescribed
If prescribing EHF milk please use most cost effective ie similac alimentum
Lactose free milks should not be recommended or prescribed
Soya milk not suitable for <6months old
‘Other’ mammal milks also not recommended
Other EHFs same but may have different tastes – possible to trial another EHF if taste not tolerated but symptoms improve on similac alimentum
Review appointments important – child will improve in 2 weeks if going to respond

41. Prepare for milk ladder
Prepare for weaning at the time of diagnosis
Milk free weaning and check labels
If gets symptoms on weaning when excluding milk also exclude soya.
Prepare for stopping the milk at start of treatment.
Life-long treatment not needed for most
Prescribed milks can usually be changed to alternatives at age 1.
Locally training up HV to be CMPA champions and to run special weaning groups

42. Milk ladder
Often when looking at milk ladder children will have tried some of the options already, start at the step they have already tolerated and trial the amounts indicated. Stop at point of symptoms and go back to step where symptoms were not present. Try again with next step 1month later.
Total failure to tolerate milk – go back to milk free diet and try again in 3 months or 1 year of age

43. Milks to substitute after 1yr
Must be calcium fortified milks ie not organic
Soya, Oat, hemp, coconut or almond milk can be trialled
Rice milk should not be a main drink until 4.5yrs
All these milks can be used in cooking from 6months

44. Myth busting
All children on prescribed milks need to be referred to allergy clinic or dietician for approval
Refer to allergy clinic if IgE symptoms or FTT or symptoms do not resolve with treatment.
Refer to allergy clinic if prescribing AA formula due to non response to EHF
Refer to dietician if parents struggling with milk free diet, weaning, how to exclude, use of milk ladder.

45. Myth busting Testing needed for non IgE - CMPA
Clinical dx with the re-trial of CMP after exclusion to confirm dx
Pre-weaning allergy testing needed for other foods as allergic to milk
No benefit unless child has shown other reactions at weaning
Possible exception with severe eczema

46. Allergy service from April 2017
Central referral form
Triaged by allergy clinic team
Assigned to community allergy clinic or secondary care team
At community clinic to be seen by specialist nurse, skin prick testing as needed and see dietician same day
Secondary care clinic – to see allergy specialist, skin prick testing as needed and access to dietician
Refer back to primary care with diagnosis and plan +/= direct dietician follow up.

47. Websites and resources
Flow chart for ref or MAP guideline
Milk ladder
– recipes for breast feeding mums

48. Basics of Paediatric Allergy 1st November 2016
DR Neha Khanna
Consultant Paediatrician
Princess Alexandra Hospital NHS Trust

49. Intend to cover Basics of food allergy
Understanding tests and diagnosis
When to prescribe Adrenaline auto injector
When to refer to Allergy clinic

50. Atopy
A genetic predisposition to producing IgE antibodies to common environmental antigens
Associated with a constellation of common conditions:
Asthma, eczema, rhinitis, conjunctivitis, urticaria, anaphylaxis.

51. The Atopic march

52. Classification: European
Adverse reaction to food
Non Toxic
Immune mediated (Food Allergy)
IgE mediated
Non IgE mediated
Mixed
Non Immune mediated
(Food Intolerance)
Enzymatic
Pharmacological
Others
Toxic
Johansson SG et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee
of the World Allergy Organization, October JACI. 2004;113:832-6.

53. IgE mediated Versus Non IgE mediated
Quick onset
Anaphylaxis etc.
Well defined mechanism
Easy to diagnose
Validated tests
Non IgE
Delayed onset
Eczema, reflux etc
Mechanism unclear
Harder to diagnose
No validated tests

54. Diagnosis: IgE mediated
History
Allergy tests
Food challenges

55. Skin prick testing

56. Allergy testing pros/ cons
Skin prick test
Specific IgE
Advantages
Results available immediately
Cheap
Highly sensitive
Easy to order
Disadvantages
Need trained staff
Risk (v slight) of systemic reaction
Have to hold arm still
Can’t do if recent antihistamines or if bad eczema
Expensive
Takes weeks for results
Involves a blood test

57. ImmunoCAP Measurement of Specific IgE
ImmunoCAP Class
IgE level kUA/L 6
>100 5 4
17.5 – 52.5 3 2
0.7 – 3.5 1
0.35 – 0.7
< 0.35

58. Sampson et al 1997 Results (SpIgE) Food 95% PPV (kU/L)
Likelihood ratios
Egg 6
7.2
Milk 32 25
Peanut 15
9.1
Fish 20 40

59. Sampson et al 2001 Results Food 95% PPV (kU/L) 1997 figures Egg 7 6
Milk 15 32
Peanut 14
Fish 20
Soya
65 (75% ppv 30)
N/A
Wheat
80 (75% PPV 26)

60. Diagnosis Consider IgE as giving 3 possible results low medium high
specific IgE <0.7kU/l
medium
specific IgE Grade 2 to 95% PPV published by Sampson
high
specific IgE > 95% PPV published by Sampson

61. Value of Allergy testing
Does a positive test imply allergy?
No, but makes it more likely
Can be sensitised but not allergic
Does a negative test exclude allergy?
No, but makes it less likely
Size predicts for likelihood of allergy
Size of wheal does NOT relate to severity of reaction
Negative tests are strongly predictive

62. Gold standard: Food challenge
DBPCFC
Open Food challenge: objective, reproducible symptoms
Child given graded doses of food
Final dose is a portion of the food
Challenge stopped if there is a reaction
If tolerates top dose not allergic
If reacts allergic
If unable to eat all doses inconclusive
NOT first line test!

63. Positive challenge

64. Food Allergy

65. Co-morbidities
Children with one food allergy often have others
Eczema more likely to be severe in food allergic children
Food allergy predicts for later respiratory allergy
Managing one allergic condition will impact on others
Active asthma is the major risk factor for severe allergic reactions
Nearly all recorded child death from food allergy also had poorly controlled asthma.
Some severe asthma attacks are actually anaphylaxis
Sampson HA et al .Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med Aug 6;327(6):380-4.
Roberts et al. Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study. J Allergy Clin Immunol Jul;112(1):

66. Egg allergy Peanut allergy (1:5)
Increased risk of asthma, % of egg allergic asthmatic by age 7
Egg Allergy in infancy predicts sensitisation to inhalant allergies , Nickel et al. JACI 1997
Egg Allergy in infancy predicts childhood wheeze at age 4 yr. Tariq SM et al. Pediatr Allergy Immunol 2000
Dietary baked egg in children accelerates resolution of egg allergy. Leonard et all JACI 2012

67. Management: IgE mediated
BSACI action plans
Antihistamine for mild reactions
Adrenaline for anaphylaxis

68. Anaphylaxis

69. Adrenaline Absolute: Previous Cardiovascular or respiratory reactions
Food allergy and co- existent persistent asthma
Relative
Reaction to small amounts of food (air borne, skin)
Remoteness from medical facilities
Teenagers

70. Egg allergy and Vaccines
MMR
Influenza
Yellow fever

71. MMR and Yellow Fever MMR Amount of egg protein negligible
Children with egg allergy, give MMR as normal
Documented anaphylaxis to MMR: assess by allergist
Yellow Fever
Refer to specialist centres

72. Influenza vaccine
Nasal flu vaccine (Fluenz tetra): safe in any setting in children with egg allergy including children with previous anaphylaxis to egg
SNIFFLE studies: 887 egg allergic children safely received nasal flu vaccine, only exclusion children with anaphylaxis to egg so severe requiring ventilation/PICU
Inactivated (injected) influenza vaccines that are egg free or have an ovalbumin content < 0.12 μg/ml may be used safely in primary care.

73. Refer to Allergy Clinic
Food allergies:
History of IgE mediated food allergy needing SPT
Fish and nut allergy
Persistent milk and egg allergy beyond 4 years of age
Multiple food allergies
History of Anaphylaxis
Food allergy and concomitant uncontrolled asthma
Reactions to unidentified food allergen along with asthma
Reaction to a minute or trace amount of allergen
Multiple non IgE mediated food allergies (restricted diet)
Urticaria:
Angioedema only with no urticarial lesions
Chronic urticaria (lasting more than 6 weeks) not responding to regular antihistamines
Eczema:
Severe eczema not responding to treatment, needing exclusion of food allergies
Hay fever:
Allergic rhinitis not responding to antihistamines/nasal steroids, or needs SPT
Others:
Wasp and bee sting generalised reactions
History of Immediate reactions to drugs (antibiotic reactions when no alternative class of drugs available, or requiring recurrent courses of antibiotics)

74. Please DO NOT REFER Uncomplicated non IgE mediated cow’s milk allergy
Parents asking for blanket allergy tests with no clear history of allergic reaction
Isolated Urticaria with no trigger (unless chronic and no response to regular anti histamines)
Children with mild or moderate eczema and not having any direct flare ups related to specific triggers.
All asthmatics and wheezers to look for aero allergen trigger
Children with egg allergy for vaccinations unless previous egg anaphylaxis required PICU admission
Single class antibiotic allergy in otherwise well child
We are happy to offer advice on Specific IgE blood tests requested by individual clinicians.

75. Discussion