Transcript Slide 1
The Presentation, Diagnosis, Management and Natural History of Food Allergy from Birth to Adulthood ACTION ON REACTION A 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 Food Hypersensitivity Allergic Food Hypersensitivity or Food Allergy Non-Allergic Food Hypersensitivity or ( ? Food Intolerance) Enzymatic IgE mediated Food Allergy Non IgE mediated Food Allergy ( ? Intolerance ) Pharmocologic Unknown Johannson S G et al Revised Nomenclature for Allergy for global use October 2003 JACI 2004 ; 114 : 832-6 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 ’ Clemens von Pirquet 1904 The harmless substances are usually proteins – referred to as allergens 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 ! Atopy = ‘No place’ The facility to produce IgE antibodies 1930’s 1969 Does not necessarily means the presence of illness • Atopic eczema • Allergic rhinoconjunctivitis • Asthma • Food allergy - IgE mediated clinical forms Not more science! New Nomenclature – Adverse Food Reactions Food Hypersensitivity Allergic Food Hypersensitivity or Food Allergy IgE mediated Food Allergy Non IgE mediated Food Allergy ( ? Intolerance ) Johannson S G et al Revised Nomenclature for Allergy for global use October 2003 JACI 2004 ; 114 : 832-6 Type 1 - IgE mediated Acute clinical effects in the skin the gut the airway and systemically Anaphylaxis The Allergy Syndromes in Childhood Asthma Allergic Rhinitis Anaphylaxis Food IgE Drugs Venom Latex Atopic Eczema Non IgE Food Allergy IgE Chronic Urticaria / Angioedema ISAAC World Allergy League Table 1 4 15 16 19 20 23 26 27 31 UK Ireland Malta Finland Germany France Sweden Belgium Austria Spain monitoring over 60 countries world-wide now 40% of our children ! and that is only counting: asthma, allergic rhinitis and eczema ! European Places The International Study of Asthma and Allergies in Childhood 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 – clinical reactions 0.5% 1% Tariq B.M.J. 1996 ; 313 (7056) : 514 -517 Grundy J. Et Al J Allergy Clin Immunol 2002 ; 110 : 784 - 789 The jigsaw puzzle of the increasing prevalence of allergy Family History Predicting the onset of clinical allergy % 80 70 60 50 40 % 30 20 10 0 1st Qtr Negative One Sibling allergic One Parent allergic Both Parents allergic Both parents with same allergy The jigsaw puzzle of the increasing prevalence of allergy Environment Family History “ The Hygiene Hypothesis “ or now ? “The Microbial Deprivation Hypothesis” The jigsaw puzzle of the increasing prevalence of allergy Environment Time Family Genetics History ‘ TheAllergy Atopic March ’ ” “ The March Allergic Rhinitis Atopic Eczema Asthma Food Allergy Nicolaos C. et al J Allergy Clin Immunol 2008: 122 : 500-6 A ‘Designer’ Allergic Infant atopic parents mum smokes C/section bottle fed 1st born early weaning ? male atopic siblings warm high humidity home little contact with other young children Prevalence of Allergic Disease in Early Childhood 30 25 20 % IgE mediated only 1year 2 years 4 years Cumulative 15 10 5 0 Food allergy Eczema Rhinitis Asthma Tariq S et al J Allergy Clin Immunol 1998; 101 : 587-93 IOW Study : 2001-02 birth cohort 969 infants 14 12 10 % 8 % of parents reporting perceived food reactions 6 4 2 0 3 mths. 6 mths. 9 mths. 12 mths. 1 in 4 families overall - reported possible food allergy Food Age 4 yrs. Accumulated % 5.1% Milk Egg Wheat Peanut Tree nuts Cod 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 Israel •Milk •Egg •Sesame Italy •Milk •Egg •Seafood Singapore •Birds Nest •Seafood •Egg •Milk Australia •Milk •Egg •Peanuts •Sesame Sampson HA 2005 WAO Why is Cow’s Milk Allergy the commonest Food Allergy in the world ? ! e.g.Cow’s Milk Allergy – Actual Clinical Spectrum IgE- mediated Anaphylaxis Non IgE-mediated Eosinophilic diseases of the GI tract Eosophagitis Gastritis Gastroenteritis Enteritis Colitis Urticaria Atopic Eczema Rhinitis Gastroesophageal ‘Reflux’ disease ‘Colic’ Acute Enterocolitis Constipation Gut Enteropathies T “It’s not that bad! - or maybe it is !! ” IgE Milk Egg Wheat Soya Peanut Tree nuts Kiwi fruit Sesame Fish Shellfish Non IgE Milk Egg Wheat Soya Chocolate Food additives Non – IgE mediated SKIN G.I. TRACT RESPIRATORY ‘Slower’ onset Eczema “Reflux” or vomiting Diarrhoea Constipation Faltering Growth Rhinitis Catarrhal symptoms “hurstle” Asthma IgE – mediated SKIN G.I. TRACT RESPIRATORY ‘Quicker’ onset Erythema Urticaria Angioedema / Swelling Abdominal pain Vomiting Diarrhoea Rhinitis Conjunctivitis 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. Generalised Allergic Reaction Anaphylaxis Food Items 54 (10%) 32 (56%) Drug – related 88 (17%) 3 (5%) Insects 63 (12%) 3 (5%) 313 (59%) 18 (32%) No Cause Found Cat 1 - Latex - 1 A & E attendances over 3 years - Royal Children’s Hospital - Brisbane Arch Dis Child 2006 ; 91 :173 - 176 Early warning signs of 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 Throat dry “staccato” or barking cough hoarseness difficulty 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 Positive ++ Negative Positive Normal Sensitisation Rarely allergic reaction +/-Allergic reaction Definite Allergic reaction > 95% Positive Predictive Serum levels and Skin Prick Test (SPT) levels for Peanut Allergy ‘RAST’ (kU / l) 15 SPT (mm) < 2 yr > 2 yr 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/s very full clinical History appropriate 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 groups Regular 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 In the home School Food labelling AVOIDANCE Holidays abroad “ may contain” ? Alternative sources of allergen –free food Restaurants Home – bakeries Ice-cream parlours Delicatessans “ Take – aways “ Parties How much do you feel your child is affected in each of these situations ? Scale 1 – 5 1 = not affected at all 5 = very much affected ANAPHYLAXIS CAMPAIGN 1117 FAMILIES - 2006 Appropriate Rescue Medication • Chlorphenamine antihistamine • Adrenaline 1 : 1000 • Hydrocortisone Prednisolone • β2 bronchodilator IM / IV Oral IM IM / IV Oral Inhalation Nos. of Fatalities with history of previous Systemic Reactions 29 3 3 PAST HISTORY REACTIONS NO PREVIOUS REACTIONS 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 ? Median time to respiratory or cardiac arrest 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 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 Uncommonly • Milk • Tree nuts • Egg • Peanuts • Wheat • Fish • Soya (+ other cereals) • Shellfish • Fruits • Seeds • Vegetables ? The future – Oral desensitisation Leicester – Cow’s Milk Cambridge - Peanut USA - Tree nut Japan - Egg Any Questions ?