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 60 minutes and are acute. Occasionally reactions can occur after 60 minutes up to 2 hours in unique situations such as a fatty food matrix, or food that are digested slowly.

Non-IgE-mediated symptoms can be much more delayed and are often insidious and in combination rather than isolated symptoms

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

History and Examination

Focussed history:

An EATERS history can be helpful for an allergy focussed history¹:

Also ask about:

• The child or young person’s feeding history including the age at which they were weaned and whether they were breast or formula fed. If the child is currently breastfed, consider the mother’s diet.
• Ask directly about Asthma, Eczema, Hayfever and any family history of atopy

Examination should pay particular attention to:

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

Differential Diagnoses

• Hereditary angioedema or spontaneous urticaria
• Erythema migrans and other childhood rashes
• Coeliac’s disease
• Constipation
• Viral infections e.g., Gastroenteritis
• Food poisoning
• Non-immune mediated food reactions (enzymatic, pharmacological, other)
• Food aversion
• Other non-food related allergies
• Difficulties related to infant feeding/ development
• Contact reactions with particular foods e.g. facial redness to tomatoes

Refer any of the following as urgent:

• Severe eczema in a child aged below 1 year of age where multiple food allergies are suspected by the parent or referring clinician and is not responding to an appropriate steroid cream regimen.
• Infants with moderate /severe eczema and egg and/or peanut allergy (for consideration of early introduction of allergenic foods)
• Clinical suspicion of multiple food allergies in a child aged below 1 year old
• Systemic allergic reaction (anaphylaxis) or severe delayed allergic reaction
• Confirmed / suspected IgE-mediated food allergy with concurrent asthma
• Faltering growth (NICE 2017) in combination with food allergy / severe eczema / gastrointestinal symptoms. Please include growth history as part of the referral
• Multiple food allergies causing moderate or severe dietary restriction
• Blood in stool causing haematological changes

If IgE mediated allergy is suspected, skin prick testing or specific IgE antibodies to the suspected foods and likely co-allergens can be offered. Tests should only be undertaken by healthcare professionals with the appropriate competencies to select, perform and interpret them and therefore would not routinely be expected within primary care.

Avoid a scatter gun approach with panels of tests being performed. Allergy testing should only be considered after an intricate allergy history has been completed.

Alternative testing such as kinesiology, hair analysis, IgG or Vega testing are not recommended. It should be strongly recommended that dietary exclusions are not done based on these tests.

There is no test to confirm or rule out non-IgE allergies. Instead, a 4 week exclusion of suspected allergen, followed by ‘re-challenge’ should be done.

For breast feeding mothers avoiding dairy they should be given advice on sun exposure and dietary sources of vitamin D. Additional information regarding supplementation is provided in the formulary, see Management of Vitamin D deficiency – Individuals at risk of vitamin D deficiency.

IgE-mediated Food Allergy

• Suspected IgE reactions to food should lead to avoidance of that food with referral to the paediatric allergy service for assessment. The specialist team will consider the need for testing where appropriate and further advice on management will be given. Follow up to assess tolerance as the patient grows can be considered, and discharge back to primary care with guidance may occur when the patient is stable.
• Guidance from the RCPCH advocates the provision of a Paediatric Allergy Action Plan which details allergens and medications to be used in the event of exposure

Non-IgE-mediated Food Allergy

• Step 1 - Trial elimination of the suspected allergen (4 weeks) is recommended

• Step 2 - It is extremely important to offer a reintroduction after the initial trial to test reproducibility of the reaction

• Without completing both Steps 1 and 2, a non-IgE mediated food allergy cannot be ruled in or ruled out.
• Seek advice from a dietician with appropriate competencies about nutritional adequacies, timings of elimination and reintroduction and follow-up.

Cow’s Milk Protein Allergy

• Where non-IgE CMPA is strongly considered, initiate treatment (food avoidance advice to breastfeeding mothers and calcium and vitamin D supplementation, or information on the most appropriate hypoallergenic formula or milk substitutes for formula-fed babies) in primary care.
• Where CMPA is less strongly considered, please discuss with cow’s milk allergy Dietitian team who can advise and offer input with family where needed.
• Refer to specific paediatric cow’s milk allergy dietitian if 1 year or younger. See Prescribing formulary here.
• See the full guidance on diagnosis and management of Cow’s Milk Allergy in Primary Care The Milk Allergy in Primary Care (MAP) Guideline 2019 | The GP Infant Feeding Network (UK) (gpifn.org.uk)

Egg Allergy

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 paediatric allergy specialist dietician will support the child and family around rechallenges when appropriate. A copy of the BSACI "egg ladder" can be found in Figure 1 of this document.

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, but specialist input is required as rapidly as possible.

Referral Criteria

Urgent Referral Criteria

• Severe eczema in a child aged below 1 year of age where multiple food allergies are suspected by the parent or referring clinician and is not responding to an appropriate steroid cream regimen.
• Infants with moderate /severe eczema and egg and/or peanut allergy (for consideration of early introduction of allergenic foods)
• Clinical suspicion of multiple food allergies in a child aged below 1 year old
• Systemic allergic reaction (anaphylaxis) or severe delayed allergic reaction
• Confirmed / suspected IgE-mediated food allergy with concurrent asthma
• Faltering growth (NICE 2017) in combination with food allergy / severe eczema / gastrointestinal symptoms. Please include growth history as part of the referral
• Multiple food allergies causing moderate or severe dietary restriction
• Blood in stool causing haematological changes

Routine Referral Criteria
The child or young person has:

• faltering growth in combination with one or more of the gastrointestinal symptoms described above.
• not responded to a single-allergen elimination diet.
• one or more acute systemic reactions.
• one or more severe delayed reactions.
• confirmed IgE-mediated food allergy and concurrent asthma.
• significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer.

There is:

• persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms).
• strong clinical suspicion of IgE-mediated food allergy, but allergy test results are negative.
• Clinical suspicion of multiple food allergies

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

GP Information

• NICE Food allergy in under 19’s: assessment and diagnosis
• The Milk Allergy in Primary Care (MAP) Guideline 2019 | The GP Infant Feeding Network (UK) (gpifn.org.uk)
• British Society of Allergy & Clinical Immunology Home – BSACI
• Guidance for Healthcare Professional regarding initial management of allergy in primary care Infant feeding and allergy prevention FINAL (bsaci.org)

• Department of Health Immunisation against Infectious Disease Guideline Green Book: Full (publishing.service.gov.uk)
  ¹Fifteen-minute consultation: The EATERS method for the diagnosis of food allergies. Mich Erlewyn-Lajeunesse at al, Arch Dis Child Educ Pract Ed 2019 Dec;104(6):286-291
  
  

Siblings or Children of Food Allergic Parent
Current British Society of Allergy and Clinical Immunology (BSACI) and British Dietetic Association (BDA) joint recommendation is that these children are to be weaned as normal between the ages 4-6 months when developmentally ready, without any special precautions or further delays in introduction of these foods (typically nuts in age appropriate form) into their diet. Please see detailed advice below. Early Feeding Guidance - BSACI and guidance for Health Care Professionals Infant feeding and allergy prevention FINAL (bsaci.org)

Patient Information

Siblings or Children of Food Allergic Parent
Current British Society of Allergy and Clinical Immunology (BSACI) and British Dietetic Association (BDA) joint recommendation is that these children are to be weaned as normal between the ages 4-6 months when developmentally ready, without any special precautions or further delays in introduction of these foods (typically nuts in age-appropriate form) into their diet. Please see information for parents: Infant feeding and allergy prevention PARENTS FINAL (bsaci.org)

• UHP: Rapid access clinic for Paediatric Dietitian referral for infants with Cow’s Milk Protein Allergy (CMPA)
  

• Torbay Hospital: Torbay and South Devon NHS Foundation Trust - Children’s Allergies

• RDUH-E: NHS Royal Devon | Allergy (children)

Pathway Group

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

Publication date: July 2016

Updated: January 2025