Allergy in Children: Advice for Referrers

Please see GGC Cows milk allergy guidance

If IgE-mediated reaction refer to Paediatric Allergy, and if Non-IgE mediated follow pathway.

If the history suggests anaphylaxis (see Box 1 in Food Allergy section below) refer for Paediatric Allergy outpatient appointment.   If the infant presents and is managed as anaphylaxis, they should be admitted.  Family history of allergy, even anaphylaxis, is not a reason for referral – see below.  If the history or examination suggests type 1 allergy (see Box 1) safety advice should be given (see Box 3 in Egg section below).

If the history suggests anaphylaxis (see Box 1) refer for Paediatric Allergy outpatient appointment.  Family history of allergy, even anaphylaxis, is not a reason for referral – see below.  If the child presents and is managed as anaphylaxis, they should be admitted to RHC for a period of observation.

Refer to both paediatrics and dietetics if any of:

• Multiple suspected food allergies (3 or more foods)
• Growth faltering
• Concerns about vitamin or mineral deficiency
• Feeding difficulties

For all suspected food reactions, identify IgE-mediated vs non-IgE-mediated symptoms and signs (see Box 2).

Non-IgE mediated reactions

If symptoms are non-IgE mediated, then risk of anaphylaxis is very low.  Recommend exclusion for a few weeks then reintroduction.  Consider non-allergy diagnosis e.g. gastro-oesophageal reflux, dyspepsia, coeliac disease.  If there are concerns about growth then refer to both general paediatrics and dietetics.

Egg (IgE-mediated)

1. Give safety advice (see Box 3)
2. Refer to paediatric allergy
3. MMR vaccine and nasal influenza vaccine can be given with standard precautions (see Green book on Immunisation) with the only exception being that if there is a history of “severe anaphylaxis” to egg (e.g. requiring intensive care) then influenza vaccine should be given in hospital

Peanut/Nut

1. Give safety advice (Box 3)
2. Avoid all nuts and sesame unless already eating, with exception of coconut (not a true nut)
3. Refer for routine paediatric allergy outpatient appointment
4. Prescribe an adrenaline auto-injector pen (AAI), if allergy probable and history suggests anaphylaxis, or if child uses regular preventer medication for asthma
   1. Epipen is preferred device in GGC.
   2. 2 pens should be available at all times, nursery/school will also require two (MHRA guidance).
   3. Ensure training is given for the specific pen provided – see https://www.epipen.co.uk/en-gb/patients for video and to order trainer pens

Lentil/Pea/Pulse

• Give safety advice (Box 3)
• Avoid all pulses (lentil, pea, bean, chickpea etc), plus peanut and tree nuts unless already eating, with exception of soya
• Refer for routine paediatric allergy outpatient appointment unless concern about anaphylaxis (see above)

Other Food (IgE mediated symptoms/signs)

• Give safety advice (Box 3)
• Refer for routine paediatric allergy outpatient appointment

Not all urticaria or angioedema is allergic, there are viral, autoimmune and idiopathic causes.

If history of anaphylaxis (Box 1 above), refer for paediatric allergy outpatient appointment.

If there is high suspicion of a particular food allergy (consistent reactions, within 0-60 minutes of exposure), then refer for routine paediatric allergy outpatient appointment.

If there is low suspicion of a particular food allergy (exposure to that food possible rather than definite, or not consistent, or delayed reaction), then recommend trying the food cautiously again at home with an anti-histamine available.

Stop any histamine releasing drugs, e.g. codeine, penicillin, non-steroidal anti-inflammatory drugs.

If no trigger is apparent, then do not refer “for allergy testing”, as a test is only warranted if there is reason to suspect one or more specific triggers.

If recurrent, prescribe a non-drowsy anti-histamine to be used intermittently or regularly, depending on frequency and severity of symptoms. 

If persistent/chronic, prescribe a regular non-drowsy anti-histamine and refer to dermatology if unresponsive to at least 3 different ones, each given at standard doses for at least 4-6 weeks.  Additional sedating anti-histamine can be used at night if sleep disturbed.

See also: 

• NHS Scotland Dermatology Patient Pathways: Urticaria
• NHSGGC Clinical Guidelines: Urticaria not associated with anaphylaxis, management in children

House dust mite, cat and dog allergy are common in children with eczema - see below.

The majority of children with eczema do NOT have food allergy.  If a child with eczema has consistent IgE-mediated symptoms/signs (see Box 1) to a specific food, see Food allergy above.

See also:

• NHSGGC Clinical Guidelines: Management of atopic eczema in children

For contact dermatitis (reactions only after exposure for 24 hours plus), refer to Dermatology.

There are no tests available for IgE-mediated reactions to additives, perfumes, chemicals etc.  Reactions to these products are highly unlikely to be immune mediated.

There are IgE blood and skin tests for house dust mite and various animal allergies.  They are not however highly reliable, and should not be used to justify removal of a pet from a home, or to approve introduction of a pet to a home.

Allergen avoidance advice from AllergyUK.org should be offered.  Anti-histamines can be prescribed.

There is variation between individual animals and breeds in terms of allergenicity, but “hypoallergenic” breeds can still cause problems for allergic individuals, and frequency of washing/grooming may be equally important. Regular exposure to a particular animal may induce tolerance but this is unpredictable.

IgE blood (RAST) and skin tests have poor sensitivity and specificity and should only be done when clinically indicated on the basis of a history of likely IgE-mediated reactions (see Box 1), not family history. 

Interpretation is the responsibility of the ordering clinician, and is not a reason to refer.

Do not refer for testing if there is no history of an allergic reaction, even if there is a strong family history of allergy/anaphylaxis. This is partly because the risk of allergy in this situation is less than 1 in 5 but also because the results of testing in this situation are generally negative, or ambiguous.  Just because a test is negative, is no guarantee that you might not become allergic later in life, especially if you have never been exposed to the food in question, and you don’t make them part of the routine diet.  Also delays in starting allergens in diet may have a negative impact on the child.

With regards food allergy, please recommend that the family try the suspect food at their earliest convenience, in a form that does not pose a risk of choking if under 5yrs.  For infants the recommendation is to introduce solid foods at around 6 months.

A child who has had a systemic reaction to bee or wasp sting (respiratory or cardiovascular symptoms/signs suggestive of anaphylaxis, or else with rash/angioedema at a site remote from the sting location) should be referred to Paediatric Allergy.

NICE Clinical Guideline 57: atopic eczema in under 12s 

NICE Clinical Guideline 134: suspected anaphylaxis

NICE Clinical Guideline 116: Food allergy in under 19s: assessment and diagnosis

CYANS food allergy recommendations www.cyans.scot.nhs.uk

CYANS anaphylaxis recommendations www.cyans.scot.nhs.uk

BSACI guideline: prescribing an adrenaline auto-injector. Clinical and Experimental Allergy 2016 (46) 1258–1280

Adrenaline auto-injectors: updated advice after European review.  Medicines and healthcare Regulatory Agency (MHRA).   Published:15 August 2017. Drug Safety Update volume 11 issue 1, August 2017: 3.