Signs and Symptoms

The most common foods causing allergies in children are:

Milk, egg, peanut, tree nuts, soya, fish, shellfish, wheat and kiwi fruit

IgE mediated reactions occur quickly within 2 hours and are acute.

Non IgE mediated symptoms can be much more delayed.

NICE lists the following symptoms:

The skin

The gastrointestinal system

The respiratory system
(usually in combination with one or more of the above symptoms and signs)

Other

A history of anaphylaxis (airway or circulatory compromise, unstoppable vomiting) should trigger a referral to the allergy clinic. See also the anaphylaxis referral guideline

History and Examination

Focussed history:

• the age of the child or young person when symptoms first started
• speed of onset following food contact
• duration of symptoms
• severity of reaction
• frequency
• setting of reaction (for example, at school or home)
• reproducibility on repeated exposure
• what food and how much exposure causes a reaction

Clinicians should directly ask about:

• Asthma
• Eczema
• Hayfever
• Family history of atopy

Examination should pay particular attention to:

• growth and physical signs of malnutrition
• signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic rhinitis).

Differential Diagnoses

• Hereditary angioedema or spontaneous urticaria (please refer to urticaria referral guideline)
• Concurrent viral infection
• Drug allergy
• Erythema migrans or other childhood rashes
• Gastroenteritis

Faltering growth

Multiple food allergies causing moderate or severe dietary restriction

Blood in stool causing haematological changes

Unusual history or concern about history

Specific IgE blood tests can be performed to single allergens if there is a clear history.

Avoid a scatter gun approach with panels of tests being performed.

Alternative testing such as kinesiology, hair analysis, IgG or Vega testing are not recommended.

Skin prick testing if facilities are available, or can sometimes be arranged in the allergy clinic.

IgE mediated

• Proven reactions to food should lead to avoidance of that food, with appropriate follow up to assess tolerance as the patient grows.
• Guidance from the RCPCH advocates the provision of emergency plans which can be downloaded here

Non-IgE-mediated food allergy

• Trial elimination of the suspected allergen (normally for between 2–6 weeks) is recommended.
• It is extremely important to offer a 'reintroduction' after the initial trial, to test reproducibility of the reaction.
• Seek advice from a dietician with appropriate competencies about nutritional adequacies, timing of elimination and reintroduction, and follow-up.

Cow's milk allergy is common. Formulary chapter 9 gives primary care advice on the diagnosis and management of cow's milk allergy and includes information leaflets for families.

Egg is the most common allergy in small children. It can present as an IgE mediated or non IgE mediated reaction. Baked egg is less allergenic and some will tolerate baked egg much earlier, or from the start of their allergy. A copy of the BSACI "egg ladder" can be found on page 1121 of this paper.

• The MMR vaccine does not contain egg and can be freely given in primary care to egg allergic patients
• The green book chapter 19 now has up to date guidance on influenza vaccinations and egg allergy. Further information can be found from BASCI here. Essentially, only if the patient has a history of anaphylaxis to egg do special considerations need to be applied for vaccination.
• Please take special note of children with moderate to severe eczema and/or egg allergy; new evidence found in the LEAP study suggests they should be referred to paediatric allergy between the ages of 4-11 months for early introduction of peanut to prevent peanut allergy, this should not be done at home, however specialist input is required as rapidly as possible.

Referral Criteria

As per the NICE guidelines please refer if there are any of the following criteria:

• faltering growth in combination with one or more of the gastrointestinal symptoms described above
• lack of response to a single-allergen elimination diet
• one or more acute systemic reaction or severe delayed reaction
• confirmed IgE-mediated food allergy with concurrent asthma
• significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer
• persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms) despite a lack of supporting history
• strong clinical suspicion of IgE-mediated food allergy but allergy test results are negative
• clinical suspicion of multiple food allergies
• moderate to severe eczema in an infant with egg allergy

Referral Instructions

e-Referral Service Selection

• Specialty: Children & Adolescent
• Clinic Type: Allergy
• Service: DRSS-Western-Child&Adolescent-Devon ICB-15N

Referral Form

DRSS referral form

Evidence

NICE Food allergy in under 19s: assessment and diagnosis

BSACI - Food Allergy and Food Intolerance

RPCPH Allergy Care Pathways for Children

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: January 2017