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1 Food allergy in children and young people overview bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 17 May 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

2 Page 2 of 11

3 1 Child or young person with possible food allergy in primary care and community settings Food allergy is an adverse immune response to a food. It can be classified into IgE-mediated and non-ige-mediated reactions. IgE-mediated reactions are triggered by the immunoglobulin E (IgE) antibody and are acute, frequently with rapid onset. Non-IgE-mediated reactions are usually caused by cell reactions in the immune system and are generally characterised by delayed and non-acute reactions. NICE has also produced a pathway on coeliac disease. 2 Initial recognition Consider food allergy in a child or young person who: has one or more signs and symptoms of possible food allergy [See page 7] (pay particular attention to persistent symptoms that involve different organ systems) or has had treatment for atopic eczema, gastro-oesophageal reflux disease or chronic gastrointestinal symptoms (including chronic constipation) but their symptoms have not responded adequately. See the NICE pathways on atopic eczema in children, dyspepsia and gastro-oesophageal reflux disease and constipation. Quality standards The following quality statement is relevant to this part of the pathway. Atopic eczema in under 12s quality standard 6. Specialist allergy investigation 3 NICE pathway on anaphylaxis for suspected anaphylactic episode See Anaphylaxis / Anaphylaxis overview Page 3 of 11

4 4 History and examination Do not offer allergy tests without first taking an allergy-focused clinical history. A healthcare professional with the appropriate competencies (a GP or other healthcare professional) should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person using the questions below. Allergy-focused clinical history The clinical history should include: any personal history of atopic disease (asthma, eczema or allergic rhinitis) any individual and family history of atopic disease (asthma, eczema or allergic rhinitis) or food allergy in parents or siblings details of any foods that are avoided and why an assessment of presenting symptoms and other symptoms that may be associated with food allergy (see signs and symptoms of possible food allergy [See page 7]), including: age at first onset speed of onset duration, severity and frequency setting of reaction (for example, at school or home) reproducibility of symptoms on repeated exposure what food and how much exposure to it causes a reaction cultural and religious factors that affect the child's diet who has raised the concern and suspects the food allergy what the suspected allergen is the child's feeding history, including age of weaning and whether they were breastfed or formula-fed (if the child is currently being breastfed, consider the mother's diet) details of previous treatment, including medication, for the presenting symptoms, and the response to this any response to the elimination and reintroduction of foods. Physical examination Based on the clinical history, physically examine the child or young person, paying particular attention to: Page 4 of 11

5 growth and physical signs of malnutrition signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic rhinitis). Quality standards The following quality statements are relevant to this part of the pathway. Food allergy quality standard 1. Allergy-focused clinical history 2. Diagnosing IgE-mediated food allergy 5 Information and support Offer age-appropriate information to the child or young person and their parent or carer that is relevant to the type of allergy (IgE-mediated, non-ige-mediated or mixed reactions). Include: the type of allergy suspected the risk of a severe allergic reaction potential impact on other healthcare issues such as vaccination the diagnostic process, which may include: an elimination diet followed by a possible planned rechallenge or initial food reintroduction procedure (see testing for non-ige-mediated food allergy in this pathway) skin prick tests and specific IgE antibody testing and their safety and limitations (see testing for IgE-mediated food allergy in this pathway) referral to secondary or specialist care information about the support available and details of how to contact support groups. NICE has written information for the public explaining its guidance on food allergy in children and young people. 6 Testing and referral See Food allergy in children and young people / Testing and referring for food allergy Page 5 of 11

6 7 NICE pathway on transition from children's to adults' services See Transition from children's to adults' services Page 6 of 11

7 Signs and symptoms of possible food allergy Note: this list is not exhaustive. The absence of these symptoms does not exclude food allergy. IgE-mediated Non-IgE-mediated The skin Pruritus Erythema Acute urticaria (localised or generalised) Acute angioedema (most commonly in the lips and face, and around the eyes) Pruritus Erythema Atopic eczema The gastrointestinal system Gastro-oesophageal reflux disease Angioedema of the lips, tongue and palate Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea Loose or frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Food refusal or aversion Constipation Perianal redness Pallor and tiredness Page 7 of 11

8 Faltering growth plus one or more gastrointestinal symptoms above (with or without significant atopic eczema) The respiratory system (usually in combination with one or more of the above symptoms and signs) Upper respiratory tract symptoms nasal itching, sneezing, rhinorrhoea or congestion (with or without conjunctivitis) Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath) Other Signs or symptoms of anaphylaxis or other systemic allergic reactions Glossary Anaphylaxis a severe, life-threatening, generalised or systemic hypersensitivity reaction, characterised by rapidly developing life-threatening airway, breathing and/or circulation problems, usually associated with skin and mucosal changes Angioedema swelling, similar to hives, except that the swelling is beneath the skin rather than on the surface Atopic eczema a chronic inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as folds of elbows or behind the knees; the word 'atopic' in the term atopic eczema is an indicator of the frequent association with atopy and the need to separate this Page 8 of 11

9 clinical phenotype from the ten or so other forms of eczema such as irritant, allergic contact, discoid, venous, seborrhoeic and photosensitive eczema, the terms 'atopic eczema' and 'atopic dermatitis' are synonymous Co-allergens allergies that are commonly found to be present in association with other allergies Erythema redness Food allergy an adverse immune response to a food, it can be classified into IgE-mediated and non-igemediated reactions: IgE-mediated reactions are triggered by the immunoglobulin E (IgE) antibody and are acute, frequently with rapid onset; Non-IgE-mediated reactions are usually caused by cell reactions in the immune system and are generally characterised by delayed and non-acute reactions Gastro-oesophageal reflux disease a chronic digestive disease that occurs when the contents of the stomach, including acid, flows back (refluxes) into the oesophagus (gullet) IgE immunoglobulin E (IgE) is a class of antibody. It triggers an excessive activation of certain white blood cells called mast cells and basophils resulting in an extreme inflammatory response IgE-mediated an allergic reaction triggered by the immunoglobulin E (IgE) antibody, the reaction is acute and frequently has rapid onset Mixed reactions mixed reactions involve a mixture of both IgE and non-ige responses Page 9 of 11

10 Non-IgE-mediated this type of allergy is not caused by IgE antibodies (it is usually because of cell reactions in the immune system); these reactions are generally characterised by delayed and non-acute reactions Pruritus itchy skin Systemic allergic reactions allergic reactions involving parts of the body distant to the actual site of allergen contact Urticaria raised, red, itchy welts (weals or swellings) of various sizes that seem to appear and disappear on the skin Sources Food allergy in under 19s: assessment and diagnosis (2011) NICE guideline CG116 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced Page 10 of 11

11 for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 11 of 11

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