Food Allergy Nottingham Service

07/08/2023

https://onlinelibrary.wiley.com/doi/10.1111/jhn.13130

https://petition.parliament.uk/petitions/637010

Our paper demonstrates multiple benefits of a community paediatric nursing and dietetic partnership in primary care in the early identification, diagnosis and management of food allergy. Please support this petition driven by Allergy UK to involve these key professionals in the diagnosis and management of all things related to allergy; eczema, food allergy, asthma, hay fever etc.

Accessing the right clinical care to support allergic conditions can be difficult and it is vital this is improved to save lives. I have personal experience of struggling to access adequate advice and support regarding allergies.

31/01/2023

This is a service evaluation comparison between 2 dietetic services who use the same Area Prescribing Committee cow's milk allergy guidelines but who work differently, with dietetic led care driving early diagnosis and management of suspected food allergy by dietitians providing training and working with 0-19 community nurses to identify and provide first line management strategies for symptoms of colic, reflux, constipation and potential food allergy. They subsequently refer to the dietitian following confirmation of food allergy without requiring much input from GP's. The comparative community dietetic department follows the more traditional referral path of providing dietetic support to families once the diagnosis has been made and referred to them by the GP or secondary care. Key findings for dietetic led care include a halving of GP consultations prior to diagnosis, less input from secondary care, majority of children being diagnosed before the age of complimentary feeding (

A dietetic-led model focusing on integration of care reduces GP workload for paediatric food allergy.

30/12/2017

Further to the issue raised in my post on the 7th November re oat sensitisation via emollients prior to ingestion of solids, Dr Robert Boyle based at Imperial College, London raised it at one of their allergy MDT meetings, where they identified that they do have quite a few children with oat allergy between them, but that this is generally in the context of multiple food allergy including multiple grains, wheat, rye, barley. Dr Helen Cox recalled one case of an adolescent with isolated, late onset oat allergy.
They asked Dr Isabel Skypala from the Royal Brompton hospital who is an expert on adult food allergy, and she too has a single case of a young adult woman with new onset oat allergy, in this case apparently linked to the use of oats in the bath and oat-based skin preparations for her eczema. This case is similar to an Australian case.
Dr Robert Boyle continues to say
‘And we know, or think we know, from observational mechanistic studies that allergic sensitisation to foods may occur through exposure of eczematous skin to small quantities of food allergens.
We discussed the potential issue of Balneum products and soya allergy, although we do not have a clear case of possible sensitisation here; and we discussed the (now withdrawn) peanut-oil containing Calendula cream.
Overall we did not have a consensus amongst the paediatric allergists of what a warning label might look like, but we do have a general agreement that avoiding food-containing skin products seems a sensible precaution for young children with eczema. And a recognition that IgE-mediated oat allergy is an inconvenient condition to have, since oat is a relatively widely consumed food ingredient.
The case reports do not suggest that eating oats gives long-lasting protection against the future possibility of developing an IgE-mediated oat allergy, but one approach would be to avoid oat-containing skin products until oat is included in the diet, in case that helps reduce the risk of oat allergy developing, through oral tolerance.
Sorry not to have a clearer consensus here. My personal view is that given we have so many emollients to choose from for eczema, I would not use food-containing moisturisers for children (or indeed adults) with eczema.
We have highlighted sufficient uncertainty through our team discussion, that we are going to run a project in 2018 to pull together our oat allergy cases and some controls and ask about prior use of oat-containing products on the skin.
We haven't considered the issue of delayed-type skin responses in detail - and from the French report (that I previously provided the link for) this may be a more common issue than IgE-mediated oat allergy.’
In light of this expert consensus (albeit requiring further research), I believe Nottingham will be looking at recommending avoiding food based emollients until these foods have been introduced into the diet.

21/12/2017

For all involved in the diagnosis and management of in infants and young children, here is some practical guidance I have written to help you implement the (international version of the Milk Allergy in Primary Care) guideline

07/11/2017

Should we be using food based emollients on children with eczema?

I raised the topic this week on Twitter and it has generated a lot of interest. It started with this paper on oat based emollients https://www.ncbi.nlm.nih.gov/pubmed/17919139
This was followed by a post by Alex Gazzola on the health benefits of oats and eczema http://www.allergy-insight.com/are-oats-good-for-eczema/
and comments from others in relation to increase in coconut allergy probably associated with the use of coconut oils. In the past, peanut oil was used as a base but has since been excluded due to concerns that this increased peanut allergy.
There has been a couple of other papers in relation to oats and wheat and one report of anaphylaxis to oats
https://www.ncbi.nlm.nih.gov/pubmed/24201466
http://www.jaci-inpractice.org/article/S2213-2198(15)00386-4/pdf

There has been a good review by Flohr and Mann, 2014 in JACI on the epidemiology/ potential drivers of eczema
http://onlinelibrary.wiley.com/doi/10.1111/all.12270/epdf
and more recently, a review by Du Toit and team, 2016 in Allergology International exploring the prevention of food allergy via early dietary interventions
https://ac.els-cdn.com/S132389301630106X/1-s2.0-S132389301630106X-main.pdf?_tid=8b2f45dc-c3f8-11e7-8dd5-00000aab0f01&acdnat=1510085971_1fe4b61c91203e6ccf4c457c436946d3
Both of these papers refer to the dual barrier hypothesis. This refers to the fact that in individuals without a skin barrier defect, which is often associated with mutation to filaggrin genes,water loss is minimal and the skin protects against microbes and environmental allergens. In those with transepidermal water loss (TEWL), detergents, soaps etc increase skin pH and make it more susceptible to environmental allergens such as food proteins, house dust mite, pollens, pet dander etc which can trigger eczema flares. Therefore allergic sensitisation is secondary to eczema, but can subsequently exacerbate the condition. Studies are now exploring the benefits of using emollients from birth in an attempt to reduce the risk of developing eczema and potential allergic sensitisation. It is becoming increasingly apparent that for some food allergic conditions at least i.e. peanut and egg, early introduction prior to allergic sensitisation can reduce the development of food allergy.

As a result, I have raised the issue with our medicines management team in Nottingham and a consultation process has since started between allergists and dermatologists in Nottingham and London to form a consensus on whether we should be advising caution on the use of food based emollients. The outcome is eagerly awaited.

Allergy. 2007 Nov;62(11):1251-6.

18/09/2017

https://www.allergyuk.org/health-professionals/mapguideline

This Allergy UK webpage is so useful as a quick reference to all the resources to support cow's milk allergy diagnosis in primary care:
i) Full iMAP guideline
ii) Presentation/ symptom chart
iii) Diagnosis and management chart
iv) Allergy focused clinical history questions
v) Patient fact sheet re establishing a diagnosis
vi) Home reintroduction to confirm/ exclude diagnosis
vii) Milk ladder for non-IgE mediated CMA
viii) Recipes to support the milk ladder

The updated version of the MAP guideline, authored by the original UK clinicians and supported by international experts in milk allergy.

23/08/2017

The Milk Allergy in Primary care (MAP) guidelines have been updated & amended to allow for international interpretation to support the diagnosis and management of across the world ( ). These guidelines are available via Allergy UK, which provides links to all the latest evidence, the full iMAP paper and resources to support implementation of the guidelines. This includes a simpler version of the previously published for those attempting straight forward cows milk reintroduction. It is less likely to be useful in those more sensitive children however, who may require more of an immunotherapy-type approach to drive tolerance to cows milk. Recipes also available to support the milk ladder. https://www.allergyuk.org/health-professionals/mapguideline

12/07/2017

This is an important RCT study comparing traditional spoon feeding with baby led weaning (BLISS; baby led introduction to solids), with primary outcome relating to obesity/ BMI, eating behaviours and energy self-regulation. Due to other concerns, they also addressed potential growth faltering, iron deficiency and choking.
Results suggest that allowing infants to control their eating using a baby-led approach does not affect energy intake/ body weight. It is reassuring to note that the baby led approach did not predispose children to growth faltering or iron deficiency anaemia. There were also no differences in choking episodes. Infants in the BLISS group were observed to be less fussy and had greater enjoyment of food.
It is important to note that the trial involved 8 contacts between antenatal to 9mths postpartum which may be necessary to achieve such positive outcomes, especially in relation to iron and energy intake and choking avoidance.
http://jamanetwork.com/journals/jamapediatrics/fullarticle/2634362?amp;utm_source=JAMA+PediatrPublishAheadofPrint&utm_campaign=10-07-2017

This randomized clinical trial assesses whether a baby-led approach to complementary feeding reduces the risk for overweight compared with traditional spoon-feeding among mothers in a single maternity hospital.

18/02/2017

Technical paper but a very interesting study exploring the allergenicity of a range of whey and casein based extensively hydrolysed formula, partially hydrolysed formula and an amino acid formula.
One of whey based formulas didn't show whey based allergenic fractions but did have some casein - so not free from casein and this probably wasn't hydrolysed so well.
Nutramigen products - both extensively hydrolysed and amino acid (only AAF explored) seemed to be least allergenic. http://onlinelibrary.wiley.com/doi/10.1111/all.12992/full

Several hydrolyzed cow's milk (CM) formulas are available for avoidance of allergic reactions in CM‐allergic children and for prevention of allergy development in high‐risk infants. Our aim was to compare...

06/02/2017

I love Italian food so after reading Ruth's glowing report on Anna del Conte's new free from recipe book on her Whatallergy website , I had to post it myself http://whatallergy.com/2017-02/learning-to-cook-wheat-dairy-and-tomato-free-italian

FreeFrom all'Italiana is the perfect cook book for anyone with a wheat and dairy allergy. Many recipes are also tomato free and so simple to cook.

28/01/2017

There has been a lot of understandable furore about the move for CCG's to remove as much off script as possible, including specialised infant formulas. I have been tweeting snippets of information but thought that it would be helpful to see some of the content of a letter sent this week to Croyden CCG from the BSACI, BDA specialist groups and Allergy UK as follows:
While we support the need to have guidance on the prescription of infant formula, we believe that many of these products should be maintained to some extent on prescription to ensure babies have access to the nutrition they need. Most worryingly, the consultation document appeared to state that parents of infants with cow’s milk protein allergy (CMPA) will be affected by this change. Our reading of this document is that you have confused lactose intolerance with cow’s milk allergy, which is an extremely dangerous misconception and CMPA is conspicuous by its absence in your list of proposed conditions for which infant formula and baby milk will be provided for in the future.

We strongly believe that formulas for CMPA should remain available on prescription. CMPA requires an extensively hydrolysed or amino acid formula as per Milk Allergy in Primary Care (MAP) Guidelines and BSACI guidelines for CMPA. These are not available online (only 2nd hand re-sale which is not safe), in supermarkets or over pharmacy counters without a prescription. If removed, there is likely to be a significant impact on the ability of these parents to feed their children, in cases where breast milk is not used.

22/12/2016

Australian study which shows that from dietary sources alone was not enough to meet recommended iodine intakes but alongside iodine fortification of bread, intakes were adequate. Dairy products were the greatest contributor to dietary iodine intake. Whilst fish is a good source of iodine, intakes of fish were relatively low in this cohort of pregnant women. The effects of having adequate iodine intakes during pregnancy on their offspring is yet to be evaluated.
Mandatory fortification of foods in the UK is minimal, with folic acid fortification not being supported again, so the chance of iodine fortification with less research behind it seems like a pipe dream. In the meantime, for those of you who can't drink cow's milk, certain cow's milk substitutes are starting to be fortified with iodine e.g. Alpro 1+ soya milk, Oatly fresh milk and products. You can also purchase iodised salt which I add to our homemade bread, although I can only find one supplier of iodine to a major supermarket at present.
http://onlinelibrary.wiley.com/doi/10.1111/mcn.12410/abstract?campaign=wolearlyview

Mandatory iodine fortification of bread was introduced in 2009 in Australia in response to the reemergence of iodine deficiency. The aim of this study was to assess iodine intake, urinary iodine concentration...