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NICE guidance

Food allergy in children and young people

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A new NICE guideline offers the first evidence-based advice on diagnosing and assessing foodallergies in children

  • An exclusive summary of new NICE guidance from a member of the guideline development group

Food allergies are adverse immune responses to food allergens. They are among the most common of the allergic disorders and are recognised as a major paediatric health problem in western countries.

There has been a dramatic increase in prevalence in the last 20 years, ranging from 6% to 8% in children up to three years of age across Europe and North America. Reactions can be extremely severe; hospital admissions in the UK for food allergies have increased by 500% since 1990.

In a review of allergy services in 2006, the Department of Health found considerable variations, with no agreed treatment pathways, referral criteria or service models, while many people with allergy symptoms self-care or use alternative sources of information, sometimes using non-validated tests and treatments. A new NICE guideline on allergy in children and young people offers best practice advice and is particularly relevant to practice nurses, health visitors, and other nurses working in primary and community settings.

Assessment and diagnosis

The guideline covers the assessment and diagnosis of children and young people (up to 19 years) with food allergy (food intolerance is not covered) in primary care settings. It highlights the importance of an allergy focused clinical history for all children presenting with suspected food allergy. This is the most important part of assessing what type of allergic reaction is causing the symptoms.

Food allergy can be caused by IgE (immunoglobulin)-mediated allergy; non-IgE mediated allergy and also a mixed aetiology. IgE-mediated reactions are acute and often have a rapid onset. Non-IgE mediated allergies are often delayed and characterised by non-acute reactions. Specific IgE testing, whether by skin prick or blood test, will only help to diagnose IgE mediated allergy; non-IgE mediated allergies require supervised elimination of the suspected food. In order to decide which type of testing is appropriate the right questions must be asked when taking the clinical history.

Correct diagnosis and advice based on accurate tests can help to reduce the incidence of adverse reactions resulting from traces of allergens. It also prevents unnecessary exclusion of foods which are safe and should be eaten as part of a healthy diet. Different types of tests are discussed, alongside the importance of ensuring they are only carried out by healthcare professionals with the appropriate skills to select, perform and interpret them.

Suspected food allergies can cause enormous anxiety for the child and family, and the guideline acknowledges the impact this can have on all aspects of the child’s life. It suggests information and support for families, including recommendations on the management of severe reactions, which foods to avoid, food labelling advice, alternative sources of nutrition, the safety of allergy testing and elimination diets, and other sources of support. It also offers advice to give to breastfeeding mothers of babies with suspected allergy, along with details of appropriate hypoallergenic milk formulas.

Referral

Circumstances when referral might be considered are discussed; for example for patients who have experienced an acute systemic reaction or a severe delayed reaction, or those with a confirmed food allergy and concurrent asthma. The guideline also gives recommendations for patients with significant atopic eczema where multiple food allergies are suspected; patients with faltering growth in combination with gastrointestinal symptoms, or those who have not responded to a single allergen exclusion diet.

Finally the guideline considers the effectiveness of some alternative types of allergy testing frequently available on the high street or via the internet such as the Vega test, kinesiology, and hair analysis. There is little evidence to show that these have a role to play in the diagnosis of food allergies, and they are not recommended.

Healthcare professionals involved in diagnosing food allergy in children and young people must have the relevant skills and competencies. Nurses working in primary care may wish to consider undertaking further training to develop these competencies.

Conclusion

This is the first evidence-based guideline on diagnosing and assessing food allergies in children. Its implementation will improve the care of children and young people with suspected food allergy in primary care. An accompanying cost analysis indicates early diagnosis can save money on unnecessary referrals and medications and improved patient outcomes.

The guideline Food Allergy in Children and Young People, is available for download at: guidance.nice.org.uk/CG116

Sue Clarkeis clinical lecturer in allergy and paediatric respiratory, Education for Health, a practice nurse/ health visitor in Cambridge and a member of the NICE guideline development group.

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