Up to 8% of children will develop food allergy in the UK. Paediatric allergy can be divided into IgE mediated or non IgE mediated allergy:
| Immediate-type food allergy (IgE mediated) | Delayed-type food allergy (non IgE mediated) |
| Symptoms are caused by IgE antibodies, and usually occur within 30 minutes (but certainly within 2 hours) of eating the triggering food. Mild/Moderate allergic symptoms: – Swollen lips, face or eyes – Itchy skin rash eg “hives”Abdominal pain, vomiting – Rhinitis, itchy/watery eyes. Severe symptoms (anaphylaxis): Airway: Persistent cough, swollen tongue, hoarse voice/cry. Breathing: Difficult/noisy breathing, wheezing. Consciousness: Pale or floppy, unconscious/unresponsive. | Symptoms usually happen hours to days later, and: – Resolve when that food is avoided – Recur when the food is eaten again Gut symptoms: – Recurrent abdominal pain – Feeding difficulties /reflux symptoms – Loose/frequent stools (>6-8 times/day) or constipation/infrequent stools (2 or fewer per week), occasionally blood in the stool – Poor weight gain. Skin symptoms: – Skin reddening, itching, eczema flares. Delayed type food allergy is of particular concern when the baby’s growth is also affected. Delayed type allergy is not caused by IgE antibodies and cannot cause anaphylaxis. |
An accurate history of the symptoms displayed and the associated time line with food groups is very important and determines further investigations and ongoing management. Please ensure that the following factors are considered:
What other allergenic foods are already tolerated (these MUST be kept in the diet at least twice a week and not removed)
Early onset eczema (< 3 months of life). The presence of early onset eczema increases the risk of IgE mediated allergy, especially if poorly managed. These children should be referred urgently to Paediatric Allergy MDT clinic,, and the eczema managed appropriately whilst awaiting clinic appointment – please see advice on management of Eczema in Paediatric Referrals (Healthcare Professionals). For advice regarding weaning see Management.
The presence of asthma or intermittent wheezing, especially if poorly controlled, increases the likelihood of allergic reactions. Management must be optimised prior to clinic appointment – please see advice in Paediatric Referrals (Healthcare Professionals).
Ensure good control of eczema and intermittent wheezing
Investigations – Blood tests for specific IgEs (RASTs) are of limited valueand not recommended. . We will arrange all necessary investigations during MDT clinic. We strongly advise parents against pursuing alternative allergy testing including hair strand analysis and York testing which are not validated and the results will not be considered in clinic.
Dietary advice – If the allergen is clear this should be removed from the diet until seen in clinic. Please do not recommend removal of food groups from the diet that are already tolerated, or the delayed introduction of other allergenic food groups, as this could cause allergy to these foods in the future. Children who are sensitised to, but tolerant of, a food may lose tolerance and develop allergy if that food is withdrawn from the diet.
For detailed information regarding ongoing dietary advice, including weaning advice for high risk babies, please see advice leaflets in Supporting Information for Parents and Healthcare professionals.
Siblings – the presence of a sibling with food allergy does NOT increase the risk of food allergy on its own. All food groups should be introduced in a timely fashion, with referral to clinic should an immediate type reaction occur. Useful information for parents regarding this can be found in the BSACI Summary for Parents leaflet (see supporting information).
Allergy management plan – Please put an allergy management plan in place prior to being seen in clinic. This must include an appropriate antihistamine, management of wheeze, adrenaline autoinjectors if appropriate, and a BSACI management plan – link in Supporting Information.
Indications for adrenaline autoinjector carriage are (2 to be available at all times):
Please ensure that the primary carers are trained in the use of an adrenaline autoinjector at the time of prescription. There are useful You Tube videos available to support training.
Vaccinations – All vaccinations, including MMR and seasonal influenza, are safe to be given in primary care. Please see the Department of Health Immunisation against Infectious Disease Guide (Green Book) (link in Supporting Information).
All children with immediate (IgE) type allergy should be referred to clinic. Some can be managed in General Paediatric clinic instead of Paediatric Allergy clinic. Please see referral criteria below for guidance as to which service to refer to..
Delayed (non-IgE) type allergy can initially be managed in primary care with total dietary exclusion of the triggering food for a minimum of 4 weeks, followed by reintroduction of the food to confirm or refute the diagnosis. These children can be referred directly to the Paediatric Dieticians for ongoing management if the diagnosis is clear.
For delayed-type non IgE mediated cow’s milk allergy in children, please see separate guidance.
If the reaction, food trigger, or diagnosis is unclear, please discuss further with the Paediatric Consultants via the advice line or Kinesis.
Referral criteria for MDT Allergy clinic – please refer directly to Paediatric Allergy clinic via eRS:
1) 2 or more immediate-type IgE food allergies suspected
2) Immediate type IgE mediated cow’s milk allergy suspected
3) Suspected peanut or tree nut allergies
4) History of asthma or wheeze with suspected food allergy
5) Early onset eczema ( <2 years of age) with suspected food allergy
6) Moderate to severe eczema below 6 months of age
7) History of anaphylaxis from any cause, including exercise-induced
8) Symptoms suggestive of pollen-food /oral allergy syndrome
For all other allergy related referrals please refer to General Paediatric or Paediatric Dietetic Clinics.
Please note, we do not provide a drug or venom allergy service or immunotherapy. Please refer these children directly to the Paediatric Allergy Service at the Evelina London Children’s Hospital.
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)
Information for parents regarding weaning and allergy prevention Infant feeding and allergy prevention PARENTS FINAL (bsaci.org)
BSACI Allergy Management Plans Paediatric Allergy Action Plans – BSACI
Department of Health Immunisation against Infectious Disease Guideline Green Book: Full (publishing.service.gov.uk)
The GP Infant Feeding Network www.gpifn.org.uk
