Alergias alimentarias en el niño evidencias y concenso

8/12/2019 Alergias alimentarias en el nio evidencias y concenso

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Arch Dis Chi ld2011;96(Suppl 2):i25i29. doi:10.1136/adc.2011.214502 i25

Accepted 4 May 2011

ABSTRACTAims The Royal College of Paediatrics and ChildHealth (RCPCH) Science and Research Department wascommissioned by the Department of Health to developnational care pathways for children with allergies; foodallergy is the second pathway. The pathways focus ondefining the competences required to improve the equityof care received by children with allergic conditions.Method The food allergy pathway was developed bya multidisciplinary working group and was based on acomprehensive review of the evidence. The pathwaywas reviewed by a broad group of stakeholders includingthe public and approved by the Allergy Care PathwaysProject Board and the RCPCH Clinical StandardsCommittee. The National Institute of Health and ClinicalExcellence simultaneously established a short guidelinereview of community practice for children with foodallergy; close communication was established betweenthe two groups.Results The results are presented in two sections:

a pathway algorithm and the competences. The entrypoints are defined and the ideal pathway of careis described from initial recognition and confirmeddiagnosis through to follow-up.Conclusions The range of manifestations of foodallergy/intolerance is much more diverse than hithertorecognised and diagnosis can be problematic as manypatients do not have classical IgE mediated disease. Thepathway provides a guide for training and developmentof services to facilitate improvements in delivery asclose to the patients home as possible. The authorsrecommend that this pathway is implemented locallyby a multidisciplinary team with a focus on creatingnetworks.

INTRODUCTIONFood allergy is one of the earliest manifestationsof the allergic march.1Its presence is strongly cor-related with other atopic disorders.2It can be lifethreatening34and its presence erodes quality oflife.5For certain foods, allergy is likely to be longterm, if not life long.6Finally, the prevalence offood allergy appears to be increasing.7

Quantifying the problem of food allergyDetermining the prevalence of food allergy using

the World Allergy Organization (WAO)8 defini-tion is problematic as it requires demonstration

of both sensitisation (in the case of IgE medi-ated reactions) as well as clinical reactivity, thelatter of which requires confirmation by a diffi-cult and labour intensive gold standard test thedouble blind placebo controlled food challenge(DBPCFC). Additional difficulties in determiningtrue prevalence stem from the natural history offood allergies. As the majority of children withcows milk and egg allergies outgrow these aller-gies during childhood,9a cross-sectional study ofchildren up to 18 years of age wil l not record foodallergy for those who have grown out of it.

Questionnaire-based studies are very limited.It is well established that there is a significantdiscrepancy between self-reported food hyper-sensitivity (either allergy or intolerance) and thatwhich can be confirmed by objective tests.1013A number of studies have attempted to quantifythis discrepancy.101113Approximately 20% of atwo-stage UK community studied perceived that

they had adverse food reactions. However, whenthese subjects underwent blinded food chal-lenges to eight common foods, only 1.41.8%were confirmed to have a true adverse food reac-tion.13More than 38% of children and adolescentsreported symptoms, but testing found only 4.2%were allergic.10Another study found that parentreported infant food allergy (33.7%) could only beconfirmed in 12.9% by testing and double blindplacebo controlled chal lenges.11

Which foods?The WAO definition refers generically to food.The difficulty with establishing the true popula-tion prevalence is in determining to which foodschallenges should be undertaken. One solution isto focus on the most common allergenic foods.This varies between countries and between eth-nic and social groups within countries.14Two dif-ferent approaches are used. The first is to screenwith a broad panel of foods to identify whichmost frequently induce reactions. The alternat iveis to assess the frequency of reactions to specificfoods in the scientific literature.15

Using the broad panel approach, it has beenfound that six foods (egg, peanut, milk, soy, wheatand fish) accounted for 86% of positive challenges,

although tree nuts and sesame were not part ofthe panel.16New foods continue to be introduced,

For numbered affiliations seeend of article

Correspondence toAdam T Fox, Paediatric Allergy,St Thomas Hospital, LondonSE1 7EH, UK;[email protected]

The RCPCH care pathway for food allergy inchildren: an evidence and consensus basednational approach

Adam T Fox,1,2Kate Lloyd,3Peter D Arkwright,4Debi Bhattacharya,5Trevor Brown,6

Philip Chetcuti,7Mandy East,8Jackie Gaventa,9Rosie King,10Ana Martinez,11Rosan Meyer,12Ami Parikh,13Michael Perkin,2Neil Shah,14David Tuthill,15Joanne Walsh,16Lisa Waddell,17John Warner18; on behalf of the Science andResearch Department, Royal College of Paediatrics and Child Health

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for example, kiwi17and lupin.18The common food allergensapproach found that food allergy to the eight most commonallergens (peanut, tree nuts, egg, milk, wheat, soybeans, fishand crustacean shellfish) was self-reported as 2.7%.

Other reviews have found that food allergy affects morethan 12% but less than 10% of the population (table 1).19

Risk factors

Certain risk factors for food allergy have been identified. Moreboys than girls are reported to have had reactions, but morewomen reported reactions than men (p


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not been assigned to specific health professionals or settingsin order to encourage flexibility in service delivery. However,it is envisaged that the provision of optimal care at all levels

will require close liaison between different health professionalgroups including doctors, nurses and dieticians. All specialistsshould have paediatric training in line with the principles out-lined in the Childrens National Service Framework.60

While the pathway is linear, it is important to recognise thatentry points can occur at any part of the pathway and that thepathway children follow may not be linear.

External reviewThirteen of 53 (25%) invited organisations responded, provid-ing 119 comments. The comment period was over Decemberand this may have resulted in a lower than expected response.All comments were reviewed by the FAWG and the pathway

was approved by the Allergy Care Pathways Project Board andthe RCPCH Clinical Standards Committee.

Core knowledge documentsThe working group did not identify key guidelines (coreknowledge documents) supporting the skills required todeliver this pathway. However, the forthcoming publicationby the National Institute of Health and Clinical Excellence(NICE) is ant icipated to be a core knowledge document.

DISCUSSIONThe aims and purpose of the RCPCH care pathway projectare described separately in this supplement.30 It remains a

concern that the quality of care for children with suspectedfood allergy in the UK is currently variable, and often poor.

A fundamental aim of the food allergy pathway is to improvethe path that children follow when food allergy is suspectedand to shorten the often long period before effective manage-

ment is instituted. In infants food allergy and eczema oftenco-exist and this pathway seeks to reinforce the need forhealth professionals to consider allergic comorbidities. Foracute presentations into this pathway, the RCPCH anaphy-laxis care pathway should be consulted (http://www.rcpch.ac.uk/allergy/anaphylaxis).

The entry points into the pathway are by acute anaphylacticpresentation, non-acute presentation and acute non-anaphylacticpresentation. Recognition of these symptoms will be required inmany community settings, particularly by health visitors and inprimary care, as well as in hospital emergency departments andin secondary care clinics. The challenge for this pathway willbe to determine a definitive diagnosis for food allergic childrenwith appropriate dietetic support. This pathway should aid the

development of consistent management of children with foodallergy, avoiding unnecessary use of currently scarce tertiarycare resources. Setting the competence required to deliver carewill allow many children to be managed outside of the tertiarysetting without compromising the quality of care.

Patienthealth professional partnershipThere is currently no cure for food allergy and it thereforelargely a chronic condition that requires ongoing manage-ment through avoidance strategies. The success of this workis dependent on the education of patients to appropriately self-care. In order to achieve this, healthcare professionals mustwork together with children, young people and their families.

Schools, colleges and early years settings are also importantin supporting day-to-day adherence to the management plan,

Figure 1 Food allergy pathway: methodology of evidence review.

Literature Review and Expert Opinion

Titles Screened [246]

Stage 2: Titles and Abstracts screened

[49]

Stage 1:

Reference Manager (de-duplication) [638]

Stage 2: Systematic

Review / PrimaryEvidence [36]

Stage 3: CASP CriticalAppraisal / Data

extraction

Stage 3: AGREEAppraisal / Data

extraction

Stage 2: Guidelines[13]

Handsearching referencelists of appraised papers [7]

Include [23] Include [20] Include [6] Include [5]

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or indeed, providing information on events that might drivereview of the plan. Thus, liaison with educational facilitiesis a key item on the pathway for those with an acute foodallergy. Concordance, or the agreement between the patient/family and health professional to follow a particular strategy,should be clearly established at the outset and the health pro-fessional should continue to assess adherence to the jointlyagreed plan.

Clinical implicationsNone of the RCPCH pathways define where (or by whom)care should be provided, but rather descr ibe the competencesrequired by the relevant health professional(s) to deliveroptimal care. To confirm a food allergy diagnosis, health-care professionals must be able to combine the findings ofan allergy focused clinical history with the results of scien-tifically validated allergy tests, in the case of IgE mediatedallergy, or the outcome of dietary exclusions and reintro-ductions, in the case of non-IgE mediated allergy. Much ofstandard management can occur close to the patients homewith onward referral on ly where the health professional no

longer has the competence to deliver care. Complex manage-ment (eg, multiple food allergy or high risk of anaphylaxis)should only be delivered in a multi-disciplinary sett ing withaccess to a paediatric nurse with allergy training, a paediat-ric dietician and psychosocial support; within the currentprovision of allergy services this would most likely be a ter-tiary setting.

This pathway has also been developed alongside the NICEguidance for diagnosis and assessment of food allergy in chil-dren and young people in primary care and community set-tings.61 These two documents complement each other andtogether offer clear guidance regarding initial assessment ofsuspected food allergy in primary care, the competencesneeded to safely deliver the care and appropriate referral.

The rise in allergic disease over the past decades has beenthe subject of significant media attention and the possible roleof food as a cause of numerous childhood problems is reflectedin the findings of studies looking at the prevalence of foodallergies. Venter et al11found that over 33% of parents believedtheir child had reacted to a food by the age of 3. While thestudy was able to show that in most cases such reactions werenot reproducible, it does illustrate that there is a burden of anx-iety among parents whose children do not in fact have foodallergies. Their fears can only be allayed effectively in commu-nity based care if there are the competences to not only diag-nose food allergy effectively but also to use an allergy focusedclinical history and if necessary, diagnostic tests or exclusion

diets, to rule it out.

CONCLUSIONThe RCPCH food allergy care pathway describes the stepsin ideal care for children presenting with acute (anaphylaxisand non-anaphylaxis) and non-acute food allergic symptoms.Used in conjunction with the other papers within the RCPCHallergy care pathway portfolio (in press),305962 64it representsan opportunity to improve the lives of children with al lergiesin our community.

Author Affiliations1Paediatric Allergy, St Thomas Hospital, London, UK2Division of Asthma, Allergy and Lung Biology, Guys and St Thomas NHSFoundation Trust, London, UK

3Science and Research Department, Royal College of Paediatrics and Child Health,London, UK

4Paediatric Allergy, University of Manchester, Royal Manchester ChildrensHospital, Manchester, UK5Pharmacy, NHS Norfolk, Norwich, UK6Paediatric Allergy, The Ulster Hospital, Dundonald, Belfast, UK7Paediatrics, Leeds Childrens Hospital, General Infirmary at Leeds, Leeds, UK8Anaphylaxis Campaign, Farnborough, UK9GOSH in Haringey, London, UK10Department of Allergy, Southampton University Hospital NHS Trust,Southampton, UK11Dermatology, Great Ormond Street Hospit al, London, UK12Dietetics, Imperial College NHS Healthcare Trust, London, UK13Paediatric A&E, Royal London Hospital, London, UK14Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK15Department of Paediatrics, Childrens Hospital for Wales, University Hospital ofWales, Cardiff, UK16Primary Care, Roundwell Medical Centre, Norw ich, UK17Nottingham Community Nutrition and Dietetic Serv ice, CitiHealth, NHSNottingham City, Nottingham, UK18Department of Paediatrics, Imperial College, London, UK

Acknowledgements We thank Ms Hilary Whitworth, a PhD Student at theUniversity of Southampton, who provided assistance for the evidence review,Dr Michael Perkin for contributing to the wr iting of the introduction of this paper,the RCPCH Allergy Care Pathways P roject Board who provided guidance andassistance and the RCPCH Clinical Standards team for their hard work on theapproval process, in particular Ms Katie Jones.

Funding This project was funded by the Department of Health.

Competing interests TB: MSD-UK, GSK, ALK-Abello, MEAD Johnson,Danone (Nutricia), Astra-Zeneca, Allergy NI, Schering P lough; ME: AnaphylaxisCampaign; AF: SHS International (from 2007), Danone, Mead Johnson, Lactofree,MSD, Schering-Plough, Meda, GSK, Phadia, Dorling Kindersley, ALK-Abello,Anaphylaxis Campaign, Allergy UK, Nestle, Allergy Therapeutics, Leaveitout.com,MyFoodFacts; JG: Allergy UK, Nestle Nutrition Institu te UK; NS: Nutricia; DT:Nutricia, SMA; JW: Novartis, Danone, Mead Johnson, Airsonette, Merck, AllergyTherapeutics, GSK, AstraZeneca.

Provenance and peer review Not commissioned; not externally peer reviewed.

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Adam T Fox, Kate Lloyd, Peter D Arkwright, et al.national approachchildren: an evidence and consensus basedThe RCPCH care pathway for food allergy in

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Alergias alimentarias en el niño evidencias y concenso

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