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Recognising childhood food allergy in primary care

What is food to one person may be bitter poisons to others

Titus Lucretius Carus

Introduction

Food allergy can be a complex, often, concerning condition, particularly in early childhood.

Food hypersensitivity is an umbrella term used to describe adverse reactions to food and includes food allergy, which involves the immune system, and food intolerances, which do not. Food hypersensitivity is used to describe objectively reproducible symptoms that are initiated by exposure to a defined stimulus at a dose tolerated by a normal person. Allergy is a hypersensitivity reaction that is initiated by specific immunological responses1.

Food allergy is the largest single cause of food hypersensitivity in childhood and it can be further divided into IgE mediated (immediate) reactions or non-IgE mediated (delayed) reactions. Food allergy is common with data from a large birth cohort from Cork in 2014 reporting an incidence of 4.5% in Irish children with proven immediate food allergy (it is estimated that an additional 1-2% of children have delayed food allergy)2. This is in keeping with an internationally reported prevalence of food allergy in children of between 5–10%.

It is important to distinguish food allergy, especially IgE mediated allergy, from other forms of food hypersensitivity because symptoms are replicated on subsequent exposures to that food and may, albeit rarely, cause severe or life-threatening reactions. A clear diagnosis of food allergy allows for the provision of appropriate dietary advice, the evaluation of future risks of exposure, and the delivery of appropriate treatment1. Through careful and accurate diagnosis, this will aid in avoiding the use of unnecessarily restrictive diets which may negatively impact a child’s growth and quality of life.

Factors contributing to the development of food allergy include infections, antibiotic usage, mode of delivery, genetic, prenatal exposures, method of feeding, mother’s diet and health status, season and family structure.3

Signs and Symptoms

The diagnosis of food allergy is largely based on a detailed allergy focused history and examination. Emphasis should be placed on the importance of gathering a detailed allergy focused physical history for accurate diagnosis of a food allergy. IgE mediated (immediate) food allergy usually presents as a reaction which may involve the skin, respiratory, circulatory or gastrointestinal systems1,4.

The timing of the onset of any of these symptoms is a crucial historical feature with immediate reactions occurring, usually within minutes but always within 2 hours of exposure. Urticarial rashes which are noted independent of food exposure (e.g. on waking) or that last for days are rarely due to food and usually have another cause such as a viral infection1. Consistency is also important as true food allergy will always result in a reaction when there is repeated exposure to the same form of the food. For example, a parent who is concerned that their child is allergic to milk but who can eat regular dairy ice-cream without difficulty is unlikely to have a milk allergy.

Non-IgE mediated (delayed) food allergy occurs hours or days after exposure, typically within 2-72 hours. While there are certain well-defined cell mediated conditions such as eosinophillic proctitis (allergic inflammation of the lower bowel) in infants, most non-IgE mediated food allergy is non-specific and is usually considered amongst a long list of alternative diagnoses, especially in young children. A summary of the most common symptoms associated with both IgE and non-IgE mediated food allergy include the following1,4:

  IgE Mediated Non-IgE Mediated
Skin Urticaria (acute and chronic)
Pruritis
Erythema
Angiodema (swelling)
Atopic eczema
Pruritis
Erythema
 
Gastrointestinal System Nausea and vomiting
Colicky abdominal pain
Diarrhoea
Angiodema of lips tongue and palete
Oral pruritis
Gastro oesophagealreflux
Loose of frequent stools
Abdominal pain
Colic
Constipation
Blood in stools
Perianal irritation
Food refusal
Faltering growth
Respiratory Upper respiratory tract systems
Lower respiratory tract systems
Lower respiratory tract systems
Other Anaphylaxis
Other system allgeric reactions
 

Another key aspect of an allergy focused history is to identify the presence of predisposing factors, in particular eczema. Most children with food allergy have underlying eczema and most children with severe eczema will have food allergy5. Occasionally the eczema will have resolved by the time the child presents and this information will only be available from the history, further emphasising the importance of obtaining a detailed history. Milk allergy may present without a history of eczema. However, it is unusual to have egg or peanut allergy without a history of eczema. It is very important to assess the child’s nutritional status, noting weight, length and subcutaneous fat stores to aid in determining whether child is at risk of/is suffering with faltering growth.

Diagnosis

Food allergy is often misdiagnosed, which can affect quality of life and increase the risk of faltering growth in this vulnerable population cohort. In practice, food allergy testing is currently only available for IgE mediated reactions. Confirming a diagnosis of food allergy is important as it justifies the avoidance of the suspect food allergen(s) and the implementation of an appropriate management plan. Conversely, a negative allergy test may allow for safe dietary expansion. Only when an individual demonstrates raised IgE to a food allergen (e.g. peanut) and reacts on contact with allergy symptoms, are they considered allergic1. Many individuals have a raised specific IgE but will not react on contact with the allergen; these individuals have allergic sensitisation but not allergy. This is important in order to understand allergy testing as to indiscriminately measure specific IgE or SPTs will yield many people who are sensitised but not allergic (i.e. over-diagnosis).

In the case of non-IgE mediated food allergy there is currently no validated, reliable test apart from dietary exclusion and reintroduction. Because these reactions are generally mild (although troublesome) it is generally safe to reintroduce foods at home provided there is no evidence of IgE mediate allergy nor a history of a previous severe reaction.

It is important that practitioners have awareness of “alternative” allergy tests available to patients in the community, many of which are expensive. European and American allergy associations have recommended against using Vega testing, kinesiology and hair testing on the basis that there are no studies to support their use. They also advise against using IgG (as opposed to IgE) testing to foods as there is no validated evidence to support its use at this time.

Expert recommendation regarding the accurate diagnosis of a food allergy is illustrated below.

Diagnosis of IgE-mediated food allergy
Allergy focussed Clinical History and Examination
In combination with:
SPTs +/- Specific IgE measurements
If History and SPTs / Bloods are contradictory an Oral Food Challenge (OFC) may be required
Neither SPTs or Specific IgE Measurements should be used on their own to diagnose CMA - not indicative of a clinical allergy                          
Diagnosis of non IgE-mediated food allergy
Allergy focussed Clinical History and Examination
Suspected Non IgE-mediated food allergy
Trial Elimination Diet for 2-4 weeks
Followed by Symptom Resolution during Elimination Period and Reappearance Post Reintroduction Phase
*There are no diagnotic tests to diagnose a non IgE-mediated allergy. Reintroduction after symptom resolution is of utmost importance to confirm diagnosis.

The management of food allergy will depend on the form and severity of the allergy, with appropriate support from healthcare professionals provide to parents and carers to ensure full nutritional requirements are met. For more in-depth guidance on the management of cow’s milk protein allergy (CMPA), please refer to the CMPA focused article on our website.

  1. O’Donovan et al. The Cork BASELINE Birth Cohort Study: Babies after SCOPE: Evaluating the longitudinal impact on neurological and nutritional endpoints. International Journal of Epidemiology (2015) 764-775
  2. Food Allergy in children and young people: Diagnosis and assessment of food allergy in children and young people in Primary Care and Community Settings (CG 116) National Institute for Health and Clinical Excellence (UK) 2010
  3. Lunjani et al. Allergy 2018
  4. Food Allergy in Summary www.ifan.ie
  5. Atopic eczema in children CG 57: management of atopic eczema in children from birth up to the age of 12 years. National Collaborating Centre for Women’s and Children’s Health. National Institute for Health and Clinical Excellence (UK) 2007.
  6. Fox et al. An update to the Milk Allergy in Primary Care Guideline. Journal of Clinical and Translational Allergy (2019) 9:40
  7. Meyer R et al, Cow’s Milk Protein Allergy from diagnosis to management: A very different journey for General Practitioners and Parents. Journal of Allergy and Clinical Immunology Practice (2018). 6(2):383-399
  8. Luyet D et al, BSACI Guideline for the diagnosis and management of Cow’s Milk Allergy (2014) Clinical and experimental allergy 44:642-672
  9. Best Practice for Infant Feeding in Ireland 2012(35) FSAI
  10. Ewan P et al, BSACI Guideline: prescribing an adrenaline auto-injector. Clinical and Experimental Allergy (2016) 46,1258-1280
  11. Nutrition Reference Pack for Infants (0-12 months). Community Nutrition and Dietetic Service, CHO 6 (2016) 71.

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