Last month (September 11) Allergy UK ran a GP masterclass looking at the management of paediatric food allergies in general practice, in this guest blog British Journal of Family Medicine editor Robert Mair recaps the key learning points:
The informative and quick-paced morning masterclass featured 4 clinical talks on various topics related to food allergies and the implications for general practice. It started with an overview by Dr Adam Fox on ‘The Allergic March & the Development of Food Allergies’. An informative and discursive talk, he considered everything from Pharaoh Menes’ death by a wasp sting (although the hieroglyphic for wasp and hippopotamus is the same, making verification somewhat difficult, he joked) to Dr John Bostock’s first description of hay fever in 1819 before moving onto the “Allergic March” that is seeing more and more people affected with allergies.
He said that currently 40% of children have an allergic diagnosis, before considering the link between different allergic diseases (the allergic comorbidity). For example, the presence of eczema increases the likelihood of the child developing food allergies, rhinitis worsens hay fever, and asthma increases the likelihood of the child suffering a severe reaction to food.
Looking at an average class of 30 primary school pupils, Dr Fox then considered how many children will be affected by different allergies. He stressed that some of these children would be the same, so would have a number of allergies, for example, one of the children might have a food allergy and eczema:
- 3-4 children out of a classroom of 30 will have eczema, but 12 would have suffered it at some point in their childhood
- 3 (or more) children out of a classroom of 30 are likely to have asthma
- 4 (or more) children out of a classroom of 30 will suffer from rhinitis
- 1-2 children out of a classroom of 30 are likely to have a food allergy, although 10 might think they have.
Following this, Dr Fox went on to look at the link between food allergy and eczema, and highlighted the link between severe eczema and food allergy – just short of 70% in most severe cases of eczema. He then offered up a practical approach to the management of eczema and food allergy. This included:
- Assessing the suitability of the patient
- Examining the case history
- Immediate allergy testing where appropriate
- Controlling the eczema with traditional treatments
- Consider exclusion/reintroduction to the diet to make firm diagnosis of Non IgE (Immunoglobulin E) mediated allergy
- Focus on common allergens first (e.g.; egg, peanut, milk, soya, fish etc)
- Ensure the case is followed up.
The second talk of the day was by Dr Carsten Flohr, which was a case scenario following the story of a young child through from diagnosis and assessment to referral. The child – a seven-month-old – represented a typical case that would go through Dr Flohr’s clinic. The case history included:
- Eczema since the age of 2 months
- Significant sleep disturbance, but otherwise well
- Diprobase cream and 1% Hydrocortisone ointment, but according to the parents nothing worked
- The child was still being breastfed at night, but had started formula feeding 3 months previous. Since then the eczema had got worse
- The family had avoided trying the child on egg due to a family history of egg allergy.
His talk then examined the management of the eczema as well as the need to get to the bottom of the food allergy. The big challenge was to ensure the eczema was not treated in isolation. In the first instance however, he looked at how to reduce the eczema, including using Eumovate in bursts of 5-7 days instead of virtually continuous use of 1% hydrocortisone. Once the eczema had been reduced he said ‘weekend treatment’ could be considered.
The second part of the case looked at the introduction of formula milk, which had made the eczema worse in the first place.
The first challenge was to determine if the allergy was IgE or non-IgE:
- IgE – quick onset, symptoms include wheezing, anaphylaxis, easy to diagnose and validate
- Non-IgE – delayed onset (approximately 24 hours later), symptoms include eczema and reflux, it is difficult to diagnose and validate and requires an exclusion diet to determine the allergy.
He then called for GPs to be aware of the possibility of “outside in” versus “inside out” cause to allergies. For example, if a child has eczema yet has never eaten peanuts, if a family member eats peanuts and then touches the skin, the immune system could treat this as an allergen and react against it.
Finally, Dr Flohr said it should be necessary to refer when:
- Diagnosis is uncertain
- There is need for advice on specialist treatment, such as wet wraps
- Contact allergy/dermatitis is present
- There is significant impairment to quality of life
- There is a recurrent skin infection
- Food allergy is suspected.
After a short break, Dr Fox returned to the lectern to talk about milk allergy. His talk aimed to show GPs the difference between immediate and delayed milk allergy, understand the underlying reasons and mechanisms behind it, help with the diagnosis of milk allergy and give doctors information on the management of the condition.
He initially looked at the difficulty many GPs experienced in diagnosing cow’s milk allergy, including in the case of non-IgE mediated cow’s milk allergy, an average of 18.2 GP visits over the course of 12 months are required in which to reach a correct diagnosis. A mean average, skewed by IgE mediated cow’s milk allergy of 2.2 months was given.
National Institute for Health and Care Excellence guidance on the diagnosis and assessment of food allergy in children and young people in primary care and community settings was launched in February 2011, with the aim of helping practitioners at the point of contact. The principles of the guidelines are:
- Recognise the broad range of possible presenting symptoms
- Look at an allergy-focused clinical history
- Decide whether the history indicates an IgE or non-IgE
- Test according to the suspected mechanism (either Ige or non-IgE)
- Refer as appropriate.
Food allergy should be suspected when the child presents with one or more of the following:
- Skin (e.g.: acute urticarial)
- Gut (e.g.: acute vomiting)
- Respiratory (in combination with other symptoms)
- Skin (e.g.: eczema)
- Gut (e.g.: gastro-oesophageal reflux (GOR), colic, diarrhoea)
Has had treatment for atopic eczema or gastro-oesophageal reflux disease or uncommonly chronic constipation, but have not responded sufficiently to treatment.
Dr Fox then worked through three different case studies which had all presented in different ways – a two-year-old who presented with an acute urticarial rash, a five-month-old with ongoing eczema, and an “Infant Screamer”. Against these three case studies he then applied the principles detailed above to determine if they were IgE or non-IgE, and whether they would need to be referred on to a specialist.
The final clinical talk of the day was delivered by Dr Rosan Meyer on Eosinophilic Gastrointestinal Disorder (EGID) and Food Protein Induced Enterocolitis Syndrome.
Dr Meyer said both conditions were rarely seen in GP practices, but more information on both can be found below:
For more information on EGID visit: http://www.fabed.co.uk/treatment.html
For more information on FPIES visit: http://www.allergyuk.org/childhood-food-allergy/fpies
Masterclass partners Abbott Nutrition produced the following infographic which explains the difference between food allergy and intolerance: