Last Saturday, I attended Allergy UK’s first annual conference at St Thomas’ Hospital, London. It was an incredibly informative day, combining some fascinating insights on the latest allergy research, together with stacks of practical advice on managing allergies day-to-day.
My family has been part of the allergy world for two years. On 30 April 2012, my then 20-month-old son suffered severe anaphylaxis when he bit into a peanut butter cookie, resulting in a three day spell in intensive care. In addition to his peanut allergy, eczema and asthma, we’ve since discovered he has a host of environmental allergies (grass, cat, dog, house dust mite). He had his second anaphylactic reaction in May last year, which our allergists believe was triggered by grass pollen. I was therefore attending first and foremost as a “nut mum”, but one with more than a passing interest in asthma and grass allergy too.
The overriding takeaway point for me was the need for allergy parents to know about the NICE guidelines on Food allergy in children and young people and Anaphylaxis. When should your GP refer you to an allergy clinic? When should you be offered skin prick tests? When should you be prescribed an EpiPen? These guidelines have the answer.
I’ve set out below the top tips I picked up. They’re based on my scribbles from the day – any errors are mine alone! I’ve inserted any relevant weblinks I can find.
Research on allergy management
Every reaction we’ve experienced with D has been an “immediate”, IgE mediated reaction. I haven’t got any first hand experience of “delayed” allergies or intolerances. So Professor Howarth’s explanation of how different adverse reactions are categorised was very helpful.
Professor Howarth and Dr Jo Walsh both used a diagram to explain this. Here’s my jotted copy, amalgamating the two:
During the panel discussion, an audience member asked whether intolerances could turn into allergies. Apparently, it might be that although an allergy doesn’t show up on skin prick tests (SPT) to begin with, it IS developing in the gut. The more exposure the child then has to the allergen, the more they become sensitised, until eventually the allergy shows on a SPT. So whilst, as the SPT results were initially negative, it might appear that an intolerance has become an allergy, it was in fact an allergy developing all along.
Although the experts believe that allergy is an interaction between environment and genetic factors, some patients have no family history of allergic conditions.
Today, 1 in 6 children have asthma and 40% of teenagers have hayfever.
The link between gut bacteria and allergies
One area researchers are looking at is the link between allergies and the profile of bacteria in a child’s gut. Studies have shown that reduced “microbial diversity” in the gut leads to an increased likelihood of asthma.
The normal gut process means a child becomes tolerant to foreign proteins. So scientists are researching how an abnormal bacterial profile might stop this tolerance from happening.
They are looking at various factors which “influence the infant microbiome”, for example:
- Whether the mother chews the baby’s food before giving it to the baby (apparently this is common in some cultures).
- Skin contact.
- Normal birth vs c-section (some studies have pointed to an increased asthma risk for children born by Caesarian).
What can parents do to reduce a child’s allergy risk?
There’s no magic answer to this one … yet.
There was a 2006 study (Perkin & Strachan) which suggested drinking unpasteurised milk had a protective effect. (I hasten to add, it wasn’t suggested we all start doing this – it was highlighted as an interesting link!)
Taking probiotics during the final weeks of pregnancy (and giving them to your young baby) might help… or might have zero impact. The data is conflicting.
The allergic march
The allergic march is where a child goes on to develop a range of atopic conditions. Typically the march will progress from food allergy > eczema > asthma > hay fever. One heartening stat was that food allergy is unlikely to begin after 6 years of age.
A child’s exposure to allergens
Professor Howarth discussed the link between a child’s exposure to food allergens and the risk of that child developing an allergy. Some experts now believe that both too little exposure OR too much exposure can lead to an increased risk.
The LEAP study is one to watch. This is currently investigating the issue of whether peanuts should be avoided or introduced early into a child’s diet.
The results of immunotherapy trials have been promising. Fleischer and colleagues carried out a sub lingual immunotherapy trial, where drops of peanut are given under the tongue. Researchers at Addenbrooke’s recently reported the outcome of their oral immunotherapy trial (where children were given peanut solution to drink).
In time, the principles from these trials might be applied to other allergens such as egg and fish.
Research trials are looking at whether being given Vitamin D can reduce the risk of asthma and allergy. The theory is that people with high levels of Vitamin D have a reduced allergic response. Urticaria (itchy hives) has also been linked to low vitamin D levels.
A lot of the UK receives insufficient sunlight for the required levels of Vitamin D. Sunscreen also blocks 99% of dermal vitamin D synthesis. We may need to increase our time outdoors and up our Vitamin D intake from food or supplements.
A basic understanding of allergy and treatment
Maureen Jenkins (Director of Clinical Services, Allergy UK) talked about the different allergic conditions and shared tips for allergy and anaphylaxis management. These were the key points for me:
- Allergy is an immune system response to a normally harmless substance in a sensitised atopic person.
- Allergy is proved by both testing (for example, a positive skin prick test) and a clinical history (symptoms).
- An interesting point was that not all asthma, rhinitis and eczema is allergic (although most is).
- For an allergic reaction, there is always inflammation (of the skin, eyes, airways, gut).
Types of allergic condition
- Food allergy affects 6-8% of children. It often begins with milk (which is usually outgrown by 2-3), then egg (which is usually outgrown by 3-5), then more once a baby is weaned.
- Peanut allergy has tripled in the last decade.
- If a child has severe eczema, they are more likely to get food allergies too.
- Eczema is a faulty skin barrier, which means both that moisture escapes and that bacteria and infection seep in. Itching at night leads to a disturbed sleep, which in turn leads to lethargy and poor concentration.
- Hayfever (allergic rhinitis) is like having a bad cold a lot of the time. 40% of children with hayfever drop a grade between their mock GSCE and their final GCSE. This goes up to 70% if they are taking a sedating anti-histamine.
- Hayfever can trigger asthma attacks, so if you have asthma it’s important to have your nose checked too.
- Asthma can lead to poor sleep and therefore reduced concentration. It can also cause anxiety – breathing difiiculties are frightening. Asthmatics often avoid exercise (for fear of making their symptoms worse) or social situations (if, for example, self-conscious about coughing).
- Hives (utricaria) are for the most part not related to allergy.
- Some people have recurring angiodema (deep swelling), without knowing why.
- Avoid your allergens.
- Take your medication as prescribed. Take preventative medicines. ASK your doctor how to use the medicines properly.
- For eczema, “moisturise copiously”! You should be getting through 1 tub of eczema cream a week.
- ALWAYS carry your adrenaline auto injectors (and practice regularly with a trainer pen).
- Airways in spasm – so you wheeze or can’t talk (in a school setting, don’t assume a child is okay if they’re not talking).
- Nose running.
- Rapid heart rate.
- Dropping blood pressure.
- Feeling of impending doom.
The advice to lie the patient down and raise their legs is so that you get the blood to their head.
You need a second EpiPen if they are showing no response after 5 minutes.
The key points are:
- Control asthma.
- Always carry your auto-injector.
Child allergy (Birth to 12 years)
In the afternoon, I attended GP Dr Jo Walsh’s workshop on child allergy.
The first part of the session focussed on the difference between allergies and intolerances, specifically the difference between cow’s milk protein allergy (CMPA) and lactose intolerance. I learned that as an intolerance is to do with digestion, symptoms such as a skin reaction, reflux or respiratory symptoms show a doctor that something is not just an intolerance.
Although a child can outgrow CMPA, they can then be left with a lactose intolerance because the bowel wall has been damaged, and the child can’t then absorb lactose (the sugar in milk) properly. One interesting point was that you need to stick with an elimination diet for 4-6 weeks, before you can say it isn’t working (to give the bowel chance to repair, if damage is leading to the symptoms).
Symptoms of a delayed food allergy can include:
- Skin – eczema (although an acute reaction can also flare eczema).
- Bowel (anything from colic down to diarrhoea).
- Respiratory (but it is often difficult to differentiate this from a small child just being snuffly).
As regards allergy testing, the NICE guidelines Diagnosis and assessment of food allergy in children and young people in primary care and community settings set out the best practice for GPs when a food allergy is suspected. There is also information on the guidance for parents.
Testing should be carried out “based on the results of the allergy-focused clinical history”. So, there needs to have been a reaction history, and a specific IgE blood test needs to be done for just one food. GPs shouldn’t be doing screens of blood tests for lots of different foods.
The guidelines set out when a child should be referred to an allergy clinic. The criteria include:
- Faltering growth and gastrointestinal symptoms.
- Significant eczema and the parent suspects food allergies might be the cause.
- Persisting parental suspicion of food allergy, despite a lack of supporting history.
Many GPs don’t have expertise in allergy. So, if you are being refused a referral, but fit the NICE referral criteria, it might be a good idea to show the guidelines to your GP…
There is also NICE guidance on anaphylaxis. This provides that under 16s who have had emergency treatment for suspected anaphylaxis should be admitted to hospital. Before being discharged from hospital, the family should be given advice on anaphylaxis, an adrenaline auto-injector and be referred to a specialist allergy service.
As regards nursery and school, the advice was to build trust. Start by finding out if they have any experience of dealing with children with allergies. If your school doesn’t have allergy policies in place, examples can be found on the web. Effective safeguards can include a “red plate” system, where allergic children’s meals are checked twice: by the kitchen and then by the nursery staff in the child’s room. Beware of hidden dangers, such as cereal boxes being used when the children are playing shop. You can download emergency allergy action plans from the BSACI website.
Teenage allergy (13 to 18 years)
Dr Helen Brough (paediatric allergy consultant) hosted a session on the daily impact of allergies, asthma and eczema for adolescents.
Several parents attending the session reported that their teenage food allergic children now refused to eat at restaurants when out with their friends. They would sit and have a drink whilst their friends ate a meal, even it was a restaurant they had eaten at safely with their family in the past. This was an eye opener for me. You think you are doing all the right things by taking your child to restaurants and showing them how to inform the staff about the need for a nut free meal, however a teenager might still prefer to miss the meal than draw attention to themselves in front of the restaurant staff or their peers.
Whilst peanut allergy, for example, has been shown to lead to more anxiety than diabetes, there is not much psychological support. For these types of issues cognitive behavioural therapy (CBT) can be useful. Your child may be able to be referred to Child and Adolescent Mental Health Services (CAMHS) in respect of this.
Another issue covered was the age that a child might be expected to be able to self administer adrenaline. This tends to be any time from 10 years of age onwards.
How Allergy UK can help you
Towards the end of the conference, Sarah Stoneham (Allergy UK Trustee) gave an update on the work of Allergy UK, which also described her own family’s allergy journey since her daughter suffered anaphylaxis as a baby. The stand out tips for me included:
- As well as a helpline (01322 619898), there is a web chat facility on the Allergy UK website.
- There is a support contact network, where you can be matched with people with similar issues.
- Allergy UK sell a range of translation cards, from the basic (I have an allergy to…) to restaurant cards and emergency cards.
So, all in all, an extremely informative day… and those are just the sessions I attended! In addition, there was also a workshop on adult allergies (which looked at, for example, occupational allergy) and demonstrations for nasal sprays, adrenaline auto injectors and eczema creams.
Thinking of going in 2015? I’ll definitely see you there!