THE FOOD ALLERGIC CHILD - CHILDREN'S ALLERGY NURSE SPECIALIST BRENDA DEWITT - THE N+ EDUCATION HUB

The Food Allergic Child

Brenda DeWitt
Children’s Allergy Nurse Specialist
bdewitt@nhs.net

Management of Food Allergy

o   Awareness

o   Avoidance

o   Allergy Action Plan

o   Allergic reaction (Mild to Moderate)

o   Antihistamine

o   Anaphylaxis

o   Adrenaline

o   Adrenaline Auto-Injectors (AAI’s)

o   Adolescence

Awareness
                      .
Accurate diagnosis

Control of
associated allergic
disease

Assessment of
individual risk &
appropriate
avoidance advice
provided

Case Study 1 - Sam
o   8 months old

o   Atopic eczema
o   Chocolate peanut butter
    muffin
o   Urticaria (hives) initially

o   Lip & facial swelling

o   A&E, given antihistamine

o   Referred to Paediatric
    Allergy service

Sam
Skin prick test
o   Egg 7mm
o   Peanut 5mm
o   Positive (Histamine) control 3mm
o   Negative control (saline) 0mm

Advised to avoid egg and
peanut

Due to start nursery soon

Management of Food Allergy
   Awareness

   AVOIDANCE

   Allergy Action Plan

   Allergic reaction (Mild to Moderate)

   Antihistamine

   Anaphylaxis

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Avoid Oral Exposure
   Always read food
    labels

   Be familiar with
    hidden ingredients

   Understand labelling
    laws and their
    limitations

Avoid Skin Contact
Contact to intact
skin less likely to
cause severe
reactions.

Can easily turn into
an oral or mucosal
exposure

Topical preparations

Avoid cross-contamination
Transfer of allergens (e.g.
utensils)

Exposure to small
amounts of allergen is
enough to cause a serious
allergic reaction

Soap & water effective in
removing allergen traces

Avoid inhalation
Reactions associated
with active cooking

Caution with
powders & flours

Airborne allergies
very rare
(e.g. air travel)

EU Food labelling

   14 foods must always
    be labeled

   EU regulations affecting
    restaurants, takeaways,
    hotels, schools,
    hospitals, conference
    venues

October 2021

Pre-packaged foods required to
provide a full ingredients list.

Precautionary Allergen Labelling
(PAL)
o   Voluntary labelling (no
    legislation)

o   Over 40 different terms

o   Increases time & cost of
    food shopping

o   Often ignored

o   No formal guidance for
    health professionals

Accidental reactions are
common:
1  in 8 peanut-allergic children experienced at
  least one accidental reaction every year
 Over 50% of 512 infants had at least one
  reaction over 3 years follow-up

Avoidance is, therefore, inadequate on its
own
All food-allergic children need:
  ◦ Personalised Allergy Management Plan
  ◦ Allergy rescue medication
                     Paul Turner “Managing Allergies in the Real World” Imperial College

Management of Food Allergy
   Awareness

   Avoidance

   ALLERGY ACTION PLAN

   Allergic reaction (Mild to Moderate)

   Antihistamine

   Anaphylaxis

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Allergy Action Plans

Self-management plan

Accessible &
understandable

All carers need a
copy

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   ALLERGIC REACTION
    (MILD TO MODERATE)

   Antihistamine

   Anaphylaxis

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Recognising the symptoms
Severity of allergic reaction
is dependent on a variety of
factors including :

  ◦   method of exposure
      to the allergen

  ◦   individual sensitivity to
      the allergen

  ◦   concurrent allergic
      disease

Mild – Moderate Reactions

.

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   Allergic Reaction (Mild to
    Moderate)

   ANTIHISTAMINE

   Anaphylaxis

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Antihistamine
Concerns regarding
sedating side effects of
Chlorphenamine (Piriton)
for acute allergic reaction
(unless required IV)

Recommend non-sedating
antihistamine (e.g.
Cetirizine or Loratidine)
for children >1y

Sam
Sam’s mum contacts
the allergy team with
these questions:

1) Should his MMR
be given in hospital?

2) Does Sam need an
adrenaline auto-
injector?

Vaccinations & Egg Allergy

MMR – safe to give in primary care. Does
NOT contain egg protein

Flu vaccine – safe to give in primary care.
Nasal or low-ovalbumin injection

Yellow fever – contraindicated. Specialist
centres only

Who should have an
    adrenaline auto-injector (AAI)?
    Asthma and IgE-mediated
     (immediate) allergies

    Previous life-threatening
     reaction

    Significant reaction to
     trace amounts

    Difficult to avoid allergen

    Idiopathic anaphylaxis

Sam
o Avoiding    egg & peanut
o Attending    nursery with action plan in place.
o He    has antihistamine available at nursery and
 wherever Sam goes
o He    had his MMR at the GP’s with no
 difficulty
o For   continued review in allergy clinic

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   Allergic Reaction (Mild to
    Moderate)

   Antihistamine

   ANAPHYLAXIS

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Case Study 2 - Jess
15 years old, known sesame, nut, chickpea & lentil
allergies

Has an AAI at home & in school

On bus her friend gave her a nut-free cereal bar

Jess began to feel unwell with severe nausea and
abdominal cramping

She got off the bus a stop early and walked home

Anaphylaxis
Anaphylaxis is a severe systemic allergic reaction
with rapid onset

AIRWAY – persistent cough, hoarse voice,
difficulty swallowing

BREATHING – difficult or noisy breathing,
wheeze, stridor

CIRCULATION – persistent dizziness,
light-headed, pale, floppy, sleepy, unconscious

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   Allergic Reaction (Mild to
    Moderate)

   Antihistamine

   Anaphylaxis

   ADRENALINE

   Adrenaline Auto-Injectors (AAI’s)

   Adolescence

Adrenaline essentials
FIRST LINE TREATMENT –
do not hesitate to administer
Adrenaline is NOT a cure for anaphylaxis

Allergy-related symptoms should improve
within 3-5 minutes

If no improvement, can administer second
dose of adrenaline in 5 minutes

Side effects – tremor/shaking, fast heart rate,
pallor

DO NOT STAND CHILD UP!

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   Allergic Reaction (Mild to Moderate)

   Antihistamine

   Anaphylaxis

   Adrenaline

   ADRENALINE AUTO -
    INJECTORS (AAI’S)

   Adolescence

Adrenaline auto-injectors

                            .

Leeds Children’s Allergy
service recommendations:
   Nursery/Primary School (4) –
    2 - nursery/school, 2 - home

 Secondary School (3) –
1- school, 1 - home, 1 - young adult to carry

   College onwards (2) – 2 to carry

EMERADE ISSUES (28/11/19)
o   Issue with not firing (temperatures >25C)

o   All non-issued pharmacy stock has been recalled

o   Not enough UK stock of alternatives

o   Carry TWO in-date Emerade AAI’s at all times

o   Prescribe different AAI when Emerade expires

o   Prescribe 300mcg AAI instead of 500mcg

o   www.emerade-bausch.co.uk

ACTIVATED            NOT ACTIVATED

 Do not allow Emerade to get hot
 (e.g. radiators / heaters / fire / sun)

EpiPen Issues 18/11/2019
o Ongoing   manufacturing ‘challenges’

o Limited   supply

o Prescriptionvalidation – maximum of two
 EpiPen’s per prescription

o4 months extension beyond expiry date
 for selected batch numbers of EpiPen
 300mcg – www.epipen.co.uk

JEXT Issues (14/10/19)
o Importsfrom Austria of Jext 300mcg to meet
 increased demand (Austrian German).

o4 months extension beyond expiry date for
 selected batch numbers

o Limited   supply

o Check   website www.jext.co.uk

Training (Initial & Ongoing)
Essential when
initially prescribed,
if changing AAI* and
annually thereafter.

Parents, child (as
appropriate) and all
carers need training

Trainer pens (free)

Jess
o Cereal   bar contained sesame
o Emphasised    importance of checking and
 reading food labels
o AAI    teaching reinforced
o Aware    to administer adrenaline early, 999
 call & not to stand or walk
o Jess   now carrying her AAI at all times

Fatal and
      Near Fatal Anaphylaxis
o   Anaphylaxis not uncommon but death is very rare

o   Most reactions occur away from the home

o   Adolescents and young adults are at greatest risk (70% of
    mortalities between ages 12 and 21)

o   Many had no previous history of severe/anaphylactic
    reactions

o   Delayed or lack of administration of adrenaline directly
    related to fatalities.

o   Asthma (esp. poorly controlled) is a significant risk
    factor

Asthma & Anaphylaxis

Asthma symptoms
“If someone tells you that they
need their reliever inhaler
(during an allergic reaction),
that’s a very clear sign you need
to get on with the EpiPen”
          Dr. Adam Fox at coroner’s inquest of
                 Karanbir Cheema (May 2019)

Reducing the risk of allergic
reactions in schools
o Most   school classes in the UK will have one
    or two children with food allergy

o In  the UK, 17% of fatal allergic reactions in
    school-aged children happen while at school

o Need     to ensure allergy rescue medication &
    allergy care plans in place
Turner PJ, Gowland MH, Sharma V et al. Increase in hospital admissions due to anaphylaxis but no increase in fatalities: an analysis of
UK national anaphylaxis data, 1992–2012. J Allergy Clin Immunol 2015;135:956-63

Schools facing increasing pressure
& scrutiny

Issues:
 Other children had limited understanding of
allergies and effect of being exposed to allergens.
Requires targeted education.

Care plans not in place, expired/ insufficient rescue
medication, lack of awareness of allergic reaction
symptoms

Recommendations:
Promote whole school, allergy-aware
management policies
          European Academy of Allergy & Clinical Immunology (EAACI) guidelines

Free Online support for schools
ALLERGY UK –
Schools Allergy Action Group programme (SAAG)
Interactive toolkit/programme to empower secondary
schools in the UK to improve the care and wellbeing of pupils
living with allergy.

ANAPHYLAXIS CAMPAIGN –
Allergy Wise
e-learning course is designed to ensure that all staff are fully
aware of the signs and symptoms of anaphylaxis, how to
provide emergency treatment and the implications for
management of severely allergic children in school.

Generic AAI’s in schools

    www.sparepensinschools.uk

Management of Food Allergy
   Awareness

   Avoidance

   Allergy Action Plan

   Allergic Reaction (Mild to
    Moderate)

   Antihistamine

   Anaphylaxis

   Adrenaline

   Adrenaline Auto-Injectors (AAI’s)

   ADOLESCENCE

Increased risk of reactions

Independence
New responsibilities
Eating out with friends
Don’t want to be different
“I know what to avoid /
It won’t happen to me”
Kissing
Alcohol/Drugs
University

What is Transition?
Purposeful & planned
process

Empowering young people
with long term conditions
to move to an adult
oriented service

Gradual process and start
early (11 years)

Why is it important?
Food allergy & atopic conditions increasingly persist into
adulthood.

Allergies have a significant impact on quality of life and
adolescents are over represented in significant and fatal
reactions.

Provision of allergy services within adult medicine can be
limited.

No clear transition structure - leaving a high risk population
with inadequate provision.
          Calvert A, Jay N. Moving on with allergy: transition in allergy services. Clin Transl Allergy. 2015;5(Suppl 3):P6.

Transition to primary care
o How   to make an appointment

o How   to get a prescription refilled

o Regular   reviews (asthma, AAI technique)

o Seeking   help or advice

o Referrals   to adult services, if needed

“Living worried” –
    Impact on quality of life
o   Constant vigilance
o   Trusting others
o   Social events – lack of spontaneity, planning ahead
o   Financial implications
o   Holidays – hotel vs. self-catering, travel insurance
o   Impact on siblings
o   Exclusion/bullying
o   Stress, anxiety, panic attacks, eating disorders
o   Career choices – military, airline, food industry
                Info taken from Psychological Impact of Allergy Study Day Anaphylaxis Campaign 12/11/2018

‘Be careful but not fearful’

Promote
empowerment,
self management,
ensure safety and
improve quality of
life.

Thank You
PRACTICAL DEMONSTRATIONS

Adrenaline auto-injectors

Asthma inhalers

Nasal sprays
                             .

Cow’s milk alternatives