The Presentation, Diagnosis, Management and Natural History of Food Allergy from Birth to Adulthood

ACTION ON REACTIONA One Day Conference on Allergen Control

The Grand Hotel Malahide October 30th 2008

Dr. Trevor Brown Children’s Allergy Service Ulster Hospital Northern Ireland

The Two Key Aims of the Conference

• To raise the awareness of life-threatening

Food Allergies

• To provide detailed and up to date

information on such Food Allergies

“Give me neither poverty nor riches, feed me with food convenient for me”

Proverbs 30 : 8

New Nomenclature – Adverse Food Reactions

Johannson S G et al Revised Nomenclature for Allergy for global use October 2003 JACI 2004 ; 114 : 832-6

Food Hypersensitivity

Allergic Food Hypersensitivityor

Food Allergy

Non-Allergic Food Hypersensitivityor

( ? Food Intolerance)

IgE mediatedFood Allergy

Non IgE mediatedFood Allergy

( ? Intolerance )

Enzymatic

Pharmocologic

Unknown

What does the word Allergy actually mean ?

allos = ‘other’

ergon = ‘work’

‘ The inappropriate and

harmful response of the body’s

Immune system to normally

harmless substances ’

The harmless substances are

usually proteins – referred to

as allergens

Clemens von Pirquet 1904

What are the common Protein ‘Allergens’ ?

• Grass pollens• Tree pollens• House dust mite• Animal dander

e.g. cat, dog, horse• Moulds

• Food allergens

- over 160 and

still counting !

• Atopic eczema

• Allergic rhinoconjunctivitis

• Asthma

• Food allergy - IgE mediated clinical forms

The facility to produce IgE antibodies

Does not necessarily means the presence of illness

Atopy = ‘No place’ 1930’s

1969

Not more science!

New Nomenclature – Adverse Food Reactions

Johannson S G et al Revised Nomenclature for Allergy for global use October 2003 JACI 2004 ; 114 : 832-6

Food Hypersensitivity

Allergic Food Hypersensitivityor

Food Allergy

IgE mediatedFood Allergy

Non IgE mediatedFood Allergy

( ? Intolerance )

Type 1 - IgE mediated

Acute clinicaleffects

in the skinthe gut

the airwayand

systemically

Anaphylaxis

Asthma

Allergic Rhinitis

Atopic Eczema

AnaphylaxisFoodDrugsVenomLatex

Food Allergy

ChronicUrticaria / Angioedema

The Allergy Syndromes in Childhood

IgE

IgENon IgE

ISAAC World Allergy League Table1 UK

4 Ireland

15 Malta

16 Finland

19 Germany

20 France

23 Sweden

26 Belgium

27 Austria

31 Spain

EuropeanPlaces

The International Study of Asthma and Allergies in Childhood

now 40% of our children !

and that is only counting:asthma, allergic rhinitis and eczema !

monitoring over 60 countries world-wide

but are allergies becoming more common?

Yes, certainly until comparatively recently …

1964 1989 1994

Asthma 4.1% 10.2% 19.6%

Eczema 5.3% 12.0% 17.7%

Hay fever 3.2% 11.9% 12.7%

Aberdeen School Children - Russell & Helms BMJ 1997

But - recent ISAAC figures suggest that Asthma rise is levelling off in high risk countries

Allergic rhinitis and eczema rise is slowing down

and what about Food Allergy and anaphylaxis ?

Still on a worrying degree of rise !

Peanut Allergy - UK

I.O.W. Birth Cohort 1996 2002

Rate of +ve SPT’s 1% 3%

Rate reported 0.5% 1% – clinical reactions

Tariq Grundy J. Et Al B.M.J. J Allergy Clin Immunol 1996 ; 313 (7056) : 514 -517 2002 ; 110 : 784 - 789

The jigsaw puzzle of the increasing prevalence of allergy

Family

History

Predicting the onset of clinical allergy

0

10

20

30

40

50

60

70

80

1st Qtr

%

Negative OneSiblingallergic

OneParent allergic

BothParentsallergic

Both parentswith same

allergy

%

The jigsaw puzzle of the increasing prevalence of allergy

Family

History

Environment

“ The Hygiene Hypothesis “

or now ?

“The Microbial Deprivation Hypothesis”

The jigsaw puzzle of the increasing prevalence of allergy

Family

History

Environment

Genetics

Time

“ The Allergy March ”

FoodAllergy

Atopic Eczema

Allergic Rhinitis

Asthma

‘ The Atopic March ’

Nicolaos C. et al J Allergy Clin Immunol 2008: 122 : 500-6

A ‘Designer’ Allergic Infant

atopicparents

atopic siblings

1st born

male

mumsmokes

bottlefed

little contact withother young

children

early weaning ?

warmhigh humidity

home

C/section

Prevalence of Allergic Disease in Early Childhood

0

5

10

15

20

25

30

Foodallergy

Eczema Rhinitis Asthma

1year

2 years

4 years

Cumulative

Tariq S et alJ Allergy Clin Immunol 1998; 101 : 587-93

%

IgE mediatedonly

IOW Study : 2001-02 birth cohort

0

2

4

6

8

10

12

14

3 mths. 6 mths. 9 mths. 12 mths.

% of parentsreporting perceivedfood reactions

969 infants

1 in 4 families overall - reported possible food allergy

%

Food

Milk

Egg

Wheat

Peanut

Tree nuts

Cod

Age 4 yrs. Accumulated %

5 . 1 %

2 . 4

0 . 9

1 . 1

0 . 2

0 . 2

Cow Milk Allergy: World-wide

USA & UK

•Milk•Egg•Peanut•Tree Nuts•Seafood

France

•Egg•Peanuts •Milk•Mustard

Italy

•Milk•Egg•Seafood

Israel

•Milk•Egg•Sesame Australia

•Milk•Egg•Peanuts•Sesame

Singapore

•Birds Nest•Seafood•Egg•Milk

Sampson HA 2005 WAO

Why is Cow’s Milk Allergy the commonest Food Allergy in the world ?

!

IgE- mediated Non IgE-mediated

Anaphylaxis

Acute Enterocolitis

EosophagitisGastritisGastroenteritisEnteritisColitis

Eosinophilic diseases of the GI tract

Gut Enteropathies

e.g.Cow’s Milk Allergy – Actual Clinical Spectrum

Atopic Eczema

Rhinitis

Gastroesophageal‘Reflux’ disease

‘Colic’

Constipation

Urticaria

T

“It’s not that bad! - or maybe it is !! ”

IgE Non IgE

MilkEggWheatSoyaPeanutTree nutsKiwi fruitSesameFishShellfish

MilkEggWheatSoya - - - - - -ChocolateFood additives

Non – IgE mediated ‘Slower’ onset

SKIN

G.I. TRACT

RESPIRATORY

Eczema

“Reflux” or vomitingDiarrhoeaConstipationFaltering Growth

RhinitisCatarrhal symptoms “hurstle”Asthma

IgE – mediated

‘Quicker’ onset

SKIN ErythemaUrticariaAngioedema / Swelling

G.I. TRACTAbdominal painVomitingDiarrhoea

RESPIRATORYRhinitisConjunctivitis

Laryngeal oedema and/or Asthma

Anaphylaxis – Clinical definition

“ a serious allergic reaction,

that is rapid in action,

and may cause death.”

Sampson H A et al

2nd. Symposium on the definition and management

of Anaphylaxis – Summary Report

J Allergy Clin Immunol 2006 ; 117 : 391-7

Anaphylaxis

Baby death nursery fined

A nursery where an allergic child died after eating a milk product has been fined £60,000 and has been ordered to pay £19,000 costs.

Jigsaw Day Nurseries Ltd was sentenced at Aylesbury Crown Court on Thursday.

Thomas Egan, who was five months old, had been diagnosed with an allergy to all dairy products.

A nurse at the Jigsaw Day Nursery in Browns Wood, Milton Keynes, fed Thomas a breakfast cereal, not realising it contained milk.

Food Items 54 (10%) 32 (56%)

Drug – related 88 (17%) 3 (5%)

Insects 63 (12%) 3 (5%)

No Cause Found 313 (59%) 18 (32%)

Cat 1 -

Latex - 1

A & E attendances over 3 years - Royal Children’s Hospital - Brisbane Arch Dis Child 2006 ; 91 :173 - 176

Generalised Allergic Reaction

Anaphylaxis

Early warning signsof food-induced anaphylaxis

The Oral cavity a metallic taste in the mouth a tingling sensation

itching or swelling of the lips, oral mucosa, palate, or tongue

The Throatdry “staccato” or barking coughhoarsenessdifficulty breathing

Young children may just scratch at their tongue, palate, or anterior throat

Skin prick testing

Allergic sensitisation is not the same as an allergic reaction

Normal Sensitisation Definite

Rarely allergic reaction +/-Allergic reaction Allergic reaction

Negative Positive

Positive ++

> 95% Positive Predictive Serum levels and Skin Prick Test (SPT) levels

for Peanut Allergy

‘RAST’ (kU / l) SPT (mm) < 2 yr > 2 yr

15 4 8 (Grade 3/6 = 3.5-17.4)

Sporik , Hill D.

Clin Exp Allergy 2000 ; 30 : 1540 - 1546

Overall Management

There is no cure at present routinely available

for serious Food Allergy in these islands

Overall Management

• Make every effort to identify the trigger/svery full clinical Historyappropriate tests, (Skin Prick and Blood tests)+/- Challenges

• Education re Avoidance Recognising further reactions Appropriate rescue treatment

• Written Management Plan for Acute Rescue Management

• MedicAlert bracelet

• Patient Support groupsRegular Medical Follow-up

Subsequent Food Anaphylactic Reactions

80% occur outside the home

- restaurant

- school

- at a friend’s home

Pumprhey R. Lessons for management of Anaphylaxis Clin Exp Allergy 2000 ; 30 : 1144 - 50

AVOIDANCE

School “ may contain” ?In the home

Alternativesources of

allergen –free food

Restaurants

“ Take – aways “

Food labelling

Holidaysabroad

Home – bakeriesIce-cream parlours

Delicatessans

Parties

How much do you feel your child is affected in each of these situations ?

Scale 1 – 5 1 = not affected at all ANAPHYLAXIS CAMPAIGN 5 = very much affected 1117 FAMILIES - 2006

Appropriate Rescue Medication

• Chlorphenamine antihistamine IM / IV

Oral

• Adrenaline 1 : 1000 I M

• Hydrocortisone IM / IV

Prednisolone Oral

• β2 bronchodilator Inhalation

Nos. of Fatalities with historyof previous Systemic Reactions

PAST HISTORYREACTIONS

NO PREVIOUS REACTIONS

3

29

3

Bock S A et al – Fatalities to Anaphylactic Reactions to Foods J Allergy Clin Immunol 2001 : 107 : 191-3

Is there enough time for the medication to work ?

30 minutes Food

15 minutes Insect venom

5 minutes Medications Contrast reagents

Pumphrey R S Lessons for management of anaphylaxis

– from a study of fatal reactions Clin Exp Allergy 2002 ;30 :1144 -50

Median time to respiratory or cardiac arrest

Acute Management - must be ….

• Simple

• Swift

• Effective

What families need to know

• Where to go to for competent diagnosis and support

• The risk of subsequent Anaphylaxis is manageable

• Very few children need to die from it

• Children may grow out of it

• It is a whole family issue

• How to empower the older allergic child to take control

• Education of all carers is essential

• To be wary of less than competent help

• ‘Cures’ may well be just over the horizon

Natural Remission

Usually

• Milk

• Egg

• Wheat

• Soya (+ other cereals)

• Fruits

• Vegetables

Uncommonly

• Tree nuts

• Peanuts

• Fish

• Shellfish

• Seeds

Leicester – Cow’s Milk

Cambridge - Peanut

USA - Tree nut

Japan - Egg

? The future – Oral desensitisation

Any Questions ?