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The Presentation, Diagnosis, Management and Natural History of Food Allergy from Birth to Adulthood ACTION ON REACTION A One Day Conference on Allergen Control The Grand Hotel Malahide October 30th 2008 Dr. Trevor Brown Children’s Allergy Service Ulster Hospital Northern Ireland
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The Two Key Aims of the Conference
To raise the awareness of life-threatening Food Allergies To provide detailed and up to date information on such Food Allergies
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“Give me neither poverty nor riches, feed me with food convenient for me”
Proverbs 30 : 8
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New Nomenclature – Adverse Food Reactions
Johannson S G et al Revised Nomenclature for Allergy for global use October JACI ; 114 : 832-6 Food Hypersensitivity Allergic Food Hypersensitivity or Food Allergy Non-Allergic Food Hypersensitivity or ( ? Food Intolerance) Enzymatic IgE mediated Food Allergy Non IgE mediated Food Allergy ( ? Intolerance ) Pharmocologic Unknown
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What does the word Allergy actually mean ?
allos = ‘other’ ergon = ‘work’ ‘ The inappropriate and harmful response of the body’s Immune system to normally harmless substances ’ The harmless substances are usually proteins – referred to as allergens Clemens von Pirquet 1904
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What are the common Protein ‘Allergens’ ?
Grass pollens Tree pollens House dust mite Animal dander e.g. cat, dog, horse Moulds Food allergens - over 160 and still counting !
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= Atopy ‘No place’ The facility to produce IgE antibodies
1969 Does not necessarily means the presence of illness Atopic eczema Allergic rhinoconjunctivitis Asthma Food allergy - IgE mediated clinical forms
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Not more science!
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New Nomenclature – Adverse Food Reactions
Johannson S G et al Revised Nomenclature for Allergy for global use October JACI ; 114 : 832-6 Food Hypersensitivity Allergic Food Hypersensitivity or Food Allergy IgE mediated Food Allergy Non IgE mediated Food Allergy ( ? Intolerance )
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Type 1 - IgE mediated Anaphylaxis Acute clinical effects in the skin
the gut the airway and systemically Anaphylaxis
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The Allergy Syndromes in Childhood
Asthma Atopic Eczema Allergic Rhinitis Food Allergy Non IgE IgE Anaphylaxis Food Drugs Venom Latex IgE Chronic Urticaria / Angioedema
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ISAAC World Allergy League Table
1 UK 4 Ireland 15 Malta 16 Finland 19 Germany 20 France 23 Sweden 26 Belgium 27 Austria 31 Spain monitoring over 60 countries world-wide now 40% of our children ! and that is only counting: asthma, allergic rhinitis and eczema ! European Places The International Study of Asthma and Allergies in Childhood
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but are allergies becoming more common?
Yes, certainly until comparatively recently … 1964 1989 1994 Asthma 4.1% 10.2% 19.6% Eczema 5.3% 12.0% 17.7% Hay fever 3.2% 11.9% 12.7% Aberdeen School Children - Russell & Helms BMJ 1997 But - recent ISAAC figures suggest that Asthma rise is levelling off in high risk countries Allergic rhinitis and eczema rise is slowing down and what about Food Allergy and anaphylaxis ?
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Still on a worrying degree of rise !
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Peanut Allergy - UK I.O.W. Birth Cohort 1996 2002
Rate of +ve SPT’s % % Rate reported % % – clinical reactions Tariq Grundy J. Et Al B.M.J J Allergy Clin Immunol 1996 ; 313 (7056) : ; 110 :
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The jigsaw puzzle of the increasing prevalence of allergy
Family History
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Predicting the onset of clinical allergy
% Negative One Sibling allergic One Parent allergic Both Parents allergic Both parents with same allergy
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The jigsaw puzzle of the increasing prevalence of allergy
Environment Family History
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“ The Hygiene Hypothesis “ “The Microbial Deprivation Hypothesis”
or now ? “The Microbial Deprivation Hypothesis”
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The jigsaw puzzle of the increasing prevalence of allergy
Environment Time Family History Genetics
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‘ The Atopic March ’ Allergic Rhinitis Atopic Eczema Asthma Food
Allergy
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Nicolaos C. et al J Allergy Clin Immunol 2008: 122 : 500-6
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A ‘Designer’ Allergic Infant
atopic parents mum smokes C/section bottle fed 1st born male early weaning ? warm high humidity home atopic siblings little contact with other young children
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Prevalence of Allergic Disease in Early Childhood
IgE mediated only % Tariq S et al J Allergy Clin Immunol 1998; 101 :
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IOW Study : 2001-02 birth cohort
969 infants % 1 in 4 families overall - reported possible food allergy
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Accumulated % 2 . 4 0 . 9 1 . 1 0 . 2 Milk Food 5 . 1 % Egg Wheat
Peanut Tree nuts Cod Age 4 yrs. Accumulated % 5 . 1 % 2 . 4 0 . 9 1 . 1 0 . 2
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Why is Cow’s Milk Allergy the commonest Food Allergy in the world ?
!
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e.g.Cow’s Milk Allergy – Actual Clinical Spectrum
IgE- mediated Non IgE-mediated Eosophagitis Gastritis Gastroenteritis Enteritis Colitis Eosinophilic diseases of the GI tract Atopic Eczema Anaphylaxis Rhinitis Gastroesophageal ‘Reflux’ disease Urticaria ‘Colic’ Acute Enterocolitis Constipation Gut Enteropathies
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“It’s not that bad! - or maybe it is !! ”
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IgE Non IgE Milk Egg Wheat Soya Peanut Tree nuts Kiwi fruit Sesame
Fish Shellfish Milk Egg Wheat Soya - Chocolate Food additives
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Non – IgE mediated ‘Slower’ onset SKIN G.I. TRACT RESPIRATORY Eczema
“Reflux” or vomiting Diarrhoea Constipation Faltering Growth G.I. TRACT Rhinitis Catarrhal symptoms “hurstle” Asthma RESPIRATORY
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Laryngeal oedema and/or Asthma
IgE – mediated ‘Quicker’ onset Erythema Urticaria Angioedema / Swelling SKIN Abdominal pain Vomiting Diarrhoea G.I. TRACT Rhinitis Conjunctivitis RESPIRATORY Laryngeal oedema and/or Asthma
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Anaphylaxis – Clinical definition
“ a serious allergic reaction, that is rapid in action, and may cause death.” Sampson H A et al 2nd. Symposium on the definition and management of Anaphylaxis – Summary Report J Allergy Clin Immunol 2006 ; 117 : 391-7
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Anaphylaxis
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Baby death nursery fined
A nursery where an allergic child died after eating a milk product has been fined £60,000 and has been ordered to pay £19,000 costs. Jigsaw Day Nurseries Ltd was sentenced at Aylesbury Crown Court on Thursday. Thomas Egan, who was five months old, had been diagnosed with an allergy to all dairy products. A nurse at the Jigsaw Day Nursery in Browns Wood, Milton Keynes, fed Thomas a breakfast cereal, not realising it contained milk.
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Generalised Allergic Reaction Anaphylaxis Food Items 54 (10%) 32 (56%)
Drug – related (17%) (5%) Insects (12%) (5%) No Cause Found (59%) (32%) Cat Latex A & E attendances over 3 years - Royal Children’s Hospital - Brisbane Arch Dis Child 2006 ; 91 : Generalised Allergic Reaction Anaphylaxis
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Early warning signs of food-induced anaphylaxis
The Oral cavity a metallic taste in the mouth a tingling sensation itching or swelling of the lips, oral mucosa, palate, or tongue The Throat dry “staccato” or barking cough hoarseness difficulty breathing Young children may just scratch at their tongue, palate, or anterior throat
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Skin prick testing
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Allergic sensitisation is not the same as an allergic reaction
Positive ++ Negative Positive Normal Sensitisation Definite Rarely allergic reaction /-Allergic reaction Allergic reaction
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> 95% Positive Predictive Serum levels
> 95% Positive Predictive Serum levels and Skin Prick Test (SPT) levels for Peanut Allergy ‘RAST’ (kU / l) SPT (mm) < 2 yr > 2 yr (Grade 3/6 = ) Sporik , Hill D. Clin Exp Allergy 2000 ; 30 :
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Overall Management There is no cure at present routinely available
for serious Food Allergy in these islands
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Regular Medical Follow-up
Overall Management Make every effort to identify the trigger/s very full clinical History appropriate tests, (Skin Prick and Blood tests) +/- Challenges Education re Avoidance Recognising further reactions Appropriate rescue treatment Written Management Plan for Acute Rescue Management MedicAlert bracelet Patient Support groups Regular Medical Follow-up
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Subsequent Food Anaphylactic Reactions
80% occur outside the home - restaurant - school - at a friend’s home Pumprhey R. Lessons for management of Anaphylaxis Clin Exp Allergy ; 30 :
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AVOIDANCE In the home School “ may contain” ? Alternative sources of
allergen –free food Food labelling AVOIDANCE Holidays abroad Restaurants Home – bakeries Ice-cream parlours Delicatessans “ Take – aways “ Parties
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How much do you feel your child is affected in each of these situations ?
Scale 1 – 5 1 = not affected at all ANAPHYLAXIS CAMPAIGN 5 = very much affected FAMILIES
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Appropriate Rescue Medication
Chlorphenamine antihistamine IM / IV Oral Adrenaline 1 : I M Hydrocortisone IM / IV Prednisolone Oral β2 bronchodilator Inhalation
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Nos. of Fatalities with history of previous Systemic Reactions
29 3 Bock S A et al – Fatalities to Anaphylactic Reactions to Foods J Allergy Clin Immunol 2001 : 107 : 191-3
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Is there enough time for the medication to work ?
Median time to respiratory or cardiac arrest 30 minutes Food 15 minutes Insect venom 5 minutes Medications Contrast reagents Pumphrey R S Lessons for management of anaphylaxis – from a study of fatal reactions Clin Exp Allergy 2002 ;30 :
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Acute Management - must be ….
Simple Swift Effective
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What families need to know
Where to go to for competent diagnosis and support The risk of subsequent Anaphylaxis is manageable Very few children need to die from it Children may grow out of it It is a whole family issue How to empower the older allergic child to take control Education of all carers is essential To be wary of less than competent help ‘Cures’ may well be just over the horizon
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Natural Remission Usually Uncommonly Tree nuts Milk Egg Peanuts Wheat
Soya (+ other cereals) Fruits Vegetables Uncommonly Tree nuts Peanuts Fish Shellfish Seeds
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? The future – Oral desensitisation
Leicester – Cow’s Milk Cambridge - Peanut USA - Tree nut Japan - Egg
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