Download Paediatric Food allergy

Paediatric Food allergy:
Guidelines for diagnosis and
management in Primary Care
2012
Food allergy: guidelines for diagnosis and management in Primary Care
IFAN executive committee
Professor Jonathan O’B Hourihane-Chair
Dr. John Fitzsimons-Vice Chair
Ruth Charles-Honorary Secretary
IFAN core working group
Ruth Charles
Paediatric Dietitian, Irish
Nutrition & Dietetic Institute
Claire Cullinane
Clinical Nurse Specialist: Allergy
Deirdre Daly
Clinical Nurse Specialist: Allergy
Dr. John Fitzsimons
Secondary Care Paediatrics
Professor Jonathan O’B Hourihane
Tertiary Care Paediatric Allergy
Dearbhla Hunt
Paediatric Dietitian, Irish
Nutrition & Dietetic Institute
Teres a Kelly
Paediatric Dietitian, Irish
Nutrition & Dietetic Institute
Dr. Imelda Lambert
Secondary Care Paediatrics
Dr. Teresa Mc Sweeney
Senior Medical Officer, HSE
Dr. Sean O’ Callaghan
Primary Care, ICGP,
Caroline O’Connor
Community Dietitian, Irish
Nutrition & Dietetic Institute
Acknowledgements
IFAN’s work in producing these documents has been made possible by sponsors hip from
(alphabetical):
Danone Baby Nutrition, Mead Johnson Nutrition, Nutricia Advanced Medical Nutrition
,
Thermofisher Scientific, Vistapharm
Special thanks to Bronagh Clarke, UCC Department of Paediatrics & Child Health for her
efficient administration.
Thanks to Dr. James McIntosh and staff at Safefood for facilitating network meetings.
Thanks to all IFA N members for their contributions and input.
Issue dat e: /10/2012
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Review date: /10/2014
Page 2
Food allergy: guidelines for diagnosis and management in Primary Care
Contents
Page
1.
2.
4
5-6
5
6
7
7
8
9-12
9
10
10
11
12
13
14
15
16
3.
4.
5.
6.
7
8
9
Introduction
Food allergy in summary
2.1 IgE mediated food allergy
2.2 Non IgE mediated food allergy
Diagnosing food allergy in Primary Care: summary
Testing for food allergy in Primary Care: summary
Managing food allergy in Primary Care: summary
Algorithm: diagnosing and managing food allergy in Primary Care
6.1 Symptoms
6.2 History and examination
6.3 Diagnosis
6.4 Interim management
6.5 Follow up
Adrenalin autoinjectors: eduation and training in Primary Care
Glossary
Referenc es
Appendix 1. Sample emergency plan
This guidance represents the view of IFAN, which was arrived at after careful consideration of
the evidence available. Healthcare professionals are expected to take it fully into account
when exercising their clinical judgment. However, the guidance does not override the
individual responsibility of healthcare professionals to make decisions appropriate to the
circumstances of the individual patient, in consultation wit h the patient and/or guardian or
carer, and informed by the summary of product characteristics of any drugs they are
considering.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 3
Food allergy: guidelines for diagnosis and management in Primary Care
1.
Introduction
This algorithm has been designed to aid Healthcare Professionals working in Primary Care.
Its aims are to assist in diagnosis, guide int erim management and highlight when referral to
secondary/tertiary care is indicated.
At the present time there is no c ure for food allergy but it is a treatable condition best
managed with risk reduction.
Food allergy is more common than Insulin Dependent Diabetes, Epilepsy or Parkins on’s
disease.
Compromised growth, poorer nut ritional status, lower self care, poorer quality of life and
possibly lower safety in the community are less likely with accurate diagnosis.
There are many common unfounded myths for ex ample:
Myth 1. Food allergy is uncommon in infancy.
Myth 2. Allergy tests (Skin Prick Test and specific IgE) have no relevance in early infancy.
Myth 3. Consumption of milk and dairy products leads to mucus in up per and lower
respiratory tract.
Myth 4. Goat and soy milk are suitable alternatives if cow’s milk protein allergy is suspected.
Myth 5. The next allergic reaction will be wors e than the previous.
Myth 6.There is egg in the MMR vaccine.
Myth 7. Egg allergic children should be given their MMR vaccine in hospital.
You should think food allergy in a child:
-who has had one or more systemic reactions or severe delayed reactions
-with one or more of the signs and symptoms that involve different organ systems
(particularly persistent symptoms shown in the algorithm ).
-with faltering growth plus one or more gastrointestinal symptom (s)
-with early onset significant atopic eczema
1
-where optimal treatment for eczema , gastro-oesophageal reflux, chronic gastrointestinal
symptoms has not responded.
-where there is persisting parental suspicion of food allergy des pite lack of supporting
history.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 4
Food allergy: guidelines for diagnosis and management in Primary Care
2.
Food Allergy in summary
Food allergy can be classified into IgE mediated and non IgE mediated reactions.
Many non IgE reactions are believed t o be T cell mediated. Some reactions involve a mixture
of both IgE and non IgE responses and are classified as mixed IgE and non IgE allergic
reactions.
2.1 IgE mediated food allergy in primary care: key points for diagnosis and management.
1.
Very small amounts of food can elicit significant reactions.
2.
Very rapid onset of symptoms usually within 20 minutes, but often within 1-2 minutes
(World Allergy Organisation definition is within 2 hours).
3.
It is common occurring in 5-6% of young children In Ireland. The exact incidence is
unknown but is likely to be very similar to that in the UK 3-6% of preschool children
and 1-2% of older children and adults.
4.
Most children with food allergy have other atopic conditions, especially eczema
occasionally asthma and allergic rhinitis.
5.
In infants <2 years, food allergy can exacerbate existing eczema but there is no
justification for manipulating an infant or child’s diet until skin care with topical
1
steroids and emollients/ointments has been optimised . Dietary manipulation must be
short term and under experienced supervision from an allergy t eam that includes a
Dietitian.
Children >2 years with eczema should not have dietary manipulation
without expert medical assessment.
6.
Well known common food triggers (milk, egg, peanut, nuts, fish) account for more
than 90% of cases.
7.
The most common food allergies in the first few years of life include milk, egg and
peanut. In children >3y rs common food allergies include peanut, tree nuts, fish,
shellfish.
8.
Most children will outgrow allergy to milk or egg. Most children will not outgrow a
peanut, tree nut, fish or shellfish allergy.
9.
Urticaria and angioedema on their own are minor symptoms.
10. Cough and hoarseness imply upper airway obstruction, are underappreciat ed and
should be treated as severe symptoms.
11. Wheeze (even mild), feeling faint are severe symptoms.
12. Anaphylaxis is considered a severe food allergic reaction associated with lower
respiratory or cardiovascular features.
13. Many children with IgE mediat ed reactions will need to have adrenalin prescribed as
part of their care plan.
14. Children with both food allergy and asthma are at increased risk of a severe food
allergic reaction.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 5
Food allergy: guidelines for diagnosis and management in Primary Care
2.2 Non IgE mediated food allergy in primary care: key points for diagnosis and
management.
1.
Symptoms may not appear for more than 24 hours after expos ure. There may be no
response on the first day becaus e some of these mechanisms are dose related
(unlike immediat e IgE mediated reactions).
2.
A small dose may be tolerated but incremental doses are not tolerated.
3.
Symptoms are more diffuse and include enteropat hies and eczema.
4.
In infants <2 years, food allergy can exacerbate existing eczema but there is no
justification for manipulating an infant or child’s diet until skin care with topical
steroids and emollients/ointments has been optimised. Dietary manipulation must be
short term and under experienced supervision from an allergy t eam that includes a
Dietitian.
Children >2 years with eczema should not have dietary manipulation
without expert medical assessment.
5.
There is no definitive in vitro test for non IgE mediated food allergies.
6.
Dietitian supervised short term exclusion and reint roduction is the only supportable
diagnostic and possibly therapeutic intervention. This should be time defined (4-6
weeks duration) and exclude no more than 4 foods.
7.
2
Gastroint estinal (GI) syndromes include eosinophilic oesophagitis, which can present
with Gastro-oesophageal reflux disease (GORD) like symptoms, and other
eosinophilc enteropathies.
8.
Consider food allergy in c hildren with refusal to feed, s evere aversive feeding
behaviour, problems progressing the weaning diet, growth faltering etc., especially if
they also have eczema that is difficult to control.
9.
Food allergies are rarely the isolated, removable cause of upper airway symptoms
such as chronic rhino-sinusitis or middle ear disease.
Mixed IgE and non IgE symptom clusters (of the above) can occur. Non IgE mediated can
convert to IgE mediated allergy and therefore long term follow up is essential.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 6
Food allergy: guidelines for diagnosis and management in Primary Care
3.
Diagnosing food allergy in Primary Care : summary
1.
The diagnosis of food allergy depends primarily on a detailed history as outlined in
the algorithm, looking for supporting features such as reactions to common caus e
foods, clinical signs, symptoms and timing.
2.
There is no symptom or sign that is absolutely specific to allergic disease.
3.
The most important history feature is the timing of onset of symptoms after contact
with the food; IgE mediated reactions usually occur within minutes and by definition
within 2 hours of contact.
4.
Very small amounts of food can elicit significant IgE mediated reactions.
5.
Delay ed or non IgE mediated food allergy is a well recognised entity although there is
currently no validated test to confirm it.
6.
A small proportion of children wit h significant colic, gastro-oesophageal reflux or
constipation in infancy have delayed food allergy.
4.
Testing for food allergy in Primary Care: summary
1.
Testing should be focused on the suspected food (based on specific IgE and/or S kin
Prick Test (if available). RAS T refers to obsolete technology and is no longer used
2.
Multiple tests (food panels) are not recommended due to their low positive predictive
values.
3.
There is currently no validat ed test to confirm Delayed or non IgE mediated food
allergy
4.
There is no proven role for alternative allergy testing in diagnosing food allergy such
as hair analysis, isolated IgG testing, Kinesiology, Vega testing, Enzyme Potentiated
Desensitisation.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 7
Food allergy: guidelines for diagnosis and management in Primary Care
5.
Managing food allergy in Primary Care : summary
1.
The most important feature of management is the avoidance of the suspected
food, and foods that may contain it.
2.
2,3
All those with suspected c ow’s milk allergy or an allergy to more than one food
should be referred to a Paediat ric or Community Dietitian.
3.
Children with suspected delayed food allergy should follow a 4 -6 week exclusion
diet supervised by a Paediat ric or Community Dietitian followed by reintroduction
of the suspected food.
4.
Allergy Medication: rationale and recommendations.
All food allergic children should have non sedating h1 antihistamines
available in liquid form at all times.
The treatment of acute asthma requires spacer devic e inhaled beta-2agonists, however for more severe symptoms they cannot be relied on solely.
4
Indications for prescribing adrenalin autoinjectors :
Any child with a prior severe allergic reaction to the food.
Children who have had anaphylaxis or who are considered at high risk of
anaphylaxis should be prescribed adrenalin auto injectors.
Any child with food allergy and more than mild asthma (>B TS step 2)
Children living remote from medical facilities.
Most children with peanut allergy.
The dose of adrenalin is 150mc g for children <25-30kg and 300mcg for
those over 30kg as an intramuscular injection.
A child should always have 2 auto injectors with them in case the first fails or
isn’t used correctly.
When adrenalin auto injectors are prescribed there must be a clear
explanation of when and how to use them.
5.
Mild moderate allergic reactions (not involving airway or cardiovascular systems)
4
should be treated wit h an oral, non-sedative antihistamine .
6.
An allergic reaction with any respiratory or circulat ory compromise is defined as
Anaphylaxis.
7.
The treatment for anaphylaxis is intramuscular adrenalin followed by immediat e
transfer to hospital.
8.
Children with suspected food allergy and/ or anaphylaxis should be referred to a
paediatrician for confirmation and further management.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 8
Food allergy: guidelines for diagnosis and management in Primary Care
6.
DIAGNOSTI C AND MANAGEMENT ALGORITHM
5
If hyper acute presentation
Food allergy is likely in the presence of the following signs and
symptom s (not exhaustive) which can have sudden onset within 1 hour
or delayed onset after 6 hours up to 48 hours.
Emergency management of
Airway
Breathing
Circulation
6.1
IgE mediated
The skin
• Pruritus
• Erythema
• Acute urticaria (localised
or generalised)
• Acute angioedema (most
commonly in the lips and
face, and around the
eyes
The Gastrointe stinal system
• Angioedema of the lips,
tongue and palate
• Oral pruritus
• Naus ea
• Colicky abdominal pain
• Vomiting
• Diarrhoea
Non IgE mediated
•
•
•
Pruritus
Erythema
Atopic eczema
•
•
•
•
•
•
•
•
•
•
Gastro-oesophageal reflux disease
Loose or infrequent stools
Blood and/or mucus in the stools
Abdominal pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor and tiredness
Faltering growth plus one or more
gastroint estinal symptoms above
(with or without significant atopic
eczema)
The respiratory system (usually in combination with one or more of the
above symptom s and signs)
Upper respiratory tract
symptoms – nasal
itching, sneezing,
rhinorrhoea or
congestion (with or
without conjunctivitis)
Lower respiratory tract symptoms (cough, chest tightness, wheezing or
shortness of breath)
Other
Signs or symptoms of
anaphylaxis or other systemic
reactions
History and examination
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 9
Food allergy: guidelines for diagnosis and management in Primary Care
6.2 Hi story and examination
5
Ask about
Any personal history of atopic disease (asthma, eczema or allergic rhinitis)
Any individual and family history of atopic disease (asthma, eczema or allergic rhinitis)
or food allergy in parents or siblings
Details of any foods avoided and why
Presenting symptoms and other symptoms that may be associated with food allergy
(see table above) including:
-age at first onset
-speed of onset
-duration, severity and frequency
-setting of reaction (for example at school)
-reproducibility of symptoms on repeated exposure
-what food and how much exposure to it causes a reaction
Cultural and religious factors that affect the child’s diet
Who has raised the concerns and suspects the food allergy
What the suspected allergen is
The child’s feeding history, including age of weaning and whether breast fed (consider
the mother’s diet) or formula fed
Details of previous treatment, including medication for the presenting symptoms and
the response to this
Any respons e to the elimination and reintroduction of foods
6.3 If following this detailed history and examination, food allergy is
Highly unlikely
No allergy
Reint roduce all foods previously
eliminated/avoided.
Check for differentials.
Unclear/uncertain
Highly likely
Proceed with interim
management
Refer to Secondary
Care Allergy Servic e
IgE suspected
Non IgE suspected
Confirm with
specific IgE testing
for the single
suspected food
(e.g. milk/
egg/peanut only)
Refer to Paediatric/
Community
Dietitian
Proceed with
interim
management
Refer to Secondary
Care Allergy
Service
Proceed with interim
management
No testing needed
Optimise eczema
1.
management
Paediatric/Community
Dietitian supervised
4-6 week trial of food
elimination &
reintroduction
Consider other GI comorbidities e.g. Food
protein induced
enteritis.
Refer to Secondary
Care.
Interim management
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 10
Food allergy: guidelines for diagnosis and management in Primary Care
6.4 Interim management
Continue all tolerated foods
A void trigger foods-refer to “A voiding…..”
3
information sheets.
Refer to Paediatric/Community Dietitian especially if milk or more than 1 food is implicated.
Optimise Asthma management
,6,7,8
Optimise Eczema management
1
4
Prescribe allergy medication if indicat ed :
Allergy Medication: rationale and recommendations.
i. All food allergic children should have non sedating h1 antihistamines
available in liquid form at all times.
ii. The treatment of acute asthma requires spacer devic e inhaled beta-2
agonists, however for more severe symptoms they cannot be relied
on solely.
8
iii. Adrenalin autoinjector prescription is indicated for :
Any child with a prior severe allergic reaction to the food.
Children who have had anaphylaxis or who are considered at
high risk of anaphylaxis
Any child with food allergy and more than mild asthma (>B TS
step 2)
Children living remote from medical facilities.
Most children with peanut allergy.
iv. The dose of adrenalin is 150mc g for children <25-30kg and 300mcg
for those over 30kg as an intramuscular injection.
v.
A child should always have 2 auto injectors with them in case the first
fails or isn’t used correctly.
vi. When adrenalin auto injectors are prescribed there must be a clear
explanation of when and how to use them.
Follow up
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 11
Food allergy: guidelines for diagnosis and management in Primary Care
6.5 Follow up schedule
1.
Food allergy follow up is age and food dependent.
2.
Any follow up should be co-ordinated bet ween Primary and Secondary Care.
3.
Babies and infants need frequent follow up while the diagnosis is being
established, and t he nutritional issues relating to milk substitutions, micronutrient
supply etc. are stabilised.
4.
Once stable, infants need review at a relatively high frequency (maybe 2
appointments at 3 monthly interval) to assist parents in management and lifestyle
adjustment.
5.
Appointments can be spaced out to initially 6 monthly and longer thereaft er.
The clinical intention is to interfere to the minimum degree while allowing
identification as soon as possible of children whose food allergies may be
resolving, as indicated by tolerance to accidental ex posures or by changing SP T
or specific IgE levels.
6.
It is important from a family perspective to complete milk or egg challenges
before entry to primary school, when these allergies have usually resolved and
continuing avoidance, which is socially disruptive, can be stopped.
7.
Similarly, but for slightly different reasons, diagnostic or repeat peanut or tree nut
challenges should be completed by this major transition point.
8.
Once in the school system, a yearly appointment is adequate as allergies present
then are unlik ely to change quickly.
9.
In children >8 years, 2-yearly appointments with IgE focussed testing, can work,
but some families need more support.
10. Teenagers may want to be seen on their own and will often/ usually need
encouragement to carry their rescue meds and share information about their food
allergies with their peers, including new friends and partners.
11. Transition to adult services needs planning with t he family, Primary Care, school
and the local or national allergy services, especially in the coming promising era
of immunomodulatory therapies.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 12
Food allergy: guidelines for diagnosis and management in Primary Care
7.
Adrenalin autoinjectors: primary care education and training
Following diagnosis of a serious food allergy and where the child is at risk of
developing anaphylaxis training should be available for parents, teenagers, carers,
preschool staff, primary and secondary school staff. This can be provided by
Community Health Staff.
There should be a link between the Allergy Clinic and Community Health Staff to facilitate the
making of an emergency plan for each child and to enable the parent to link with staff in the
community to arrange training and follow up.
Training can be requested by parents, school staff or the allergy nurse. Following a request,
training can be arranged in a preschool or in a school. It is important to advise them in
advance that training will take an hour. Parents should be invited to attend as they will be able
to provide specific information on their child's allergy and details of any previous reactions.
The aim of training is:
1. To empower parents, carers, school staff with knowledge on allergies and allergy
avoidance
2. To enable them recognize and respond to anaphylaxis
3. To put in place an emergency plan for each child. See appendix 1 for a sample plan.
Arrangements should be made for each child to have an emergency box containing their 2
autoinjectors and any other medications that they may require. This should be clearly
labelled and stored in a safe but easily accessible location. Trainer pens are made available
during training session for participants to practice with.
Clarity regarding roles and responsibilities of parents and school staff is important.
This is detailed in the resource pack for teachers and parents "Managing chronic conditions at
9
school" .
Parents are responsible for ensuring that the medications are in date
and it is good practice to check them at the beginning of each school
term.
Teenagers are at higher risk of anaphylaxis and training should also be
offered to them. Workshops for parents and teenagers should b e
considered for this group.
Other areas to cover with parents are afterschool activities e.g. sport,
dancing, scouts. There should be a plan in place that covers those activities and this needs to
be tailored to the individual child. It will depend on the type of allergy, age of the child and
availability of the parents. Birthday parties, school tours, high risk times at school e.g.
Halloween for nut allergy will also need to be addressed.
A letter will be required for airline travel regarding the need to carry autoinjectors.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 13
Food allergy: guidelines for diagnosis and management in Primary Care
8.
Allergy Glossary
10,11
Allergen
Allergens are antigenic proteins which cause allergy
Allergic Sensitisation
Occurs when an individual who produces IgE to a particular allergen (atopic) does not have a clinical
allergic reaction when exposed to it. This is why using specific IgE as an allergy screen is
inappropriate as many people are sensitised to an allergen rather than allergic to it.
Allergy
An abnormal immune reaction to a substance which is
not in itself harmful. It can be described as
immediate or delayed. Immediate allergy is usually, but not exclusively, mediated by IgE and is also
know n as type 1 hypersensitivity
Anaphylaxis
A serious allergic reaction that involves more than one organ system (for example, skin and
respiratory tract and/or gastrointestinal tract), can begin very rapidly, and can cause death.
Angioedema
Angioedema is characterized by:
1. A sudden, pronounced swelling of the lower dermis and sub cutis
2.Sometimes pain rather than itching
3. Frequent involvement below mucous membranes
4.Resolution that is slower than for wheals and can take up to 72 h
Asthma is a chronic inflammatory disorder of the airways in which many cells play a role, in particular
mast cells, eosinophils and T lymphocytes, causes recurrent epis odes of wheezing, breathlessness,
chest tightness, and cough particularly at night and/or in the early morning. These symptoms are
usually associated with widespread but variable airflow limitation that is at least partly reversible either
spontaneously or with treatment.
Asthma
Atopy
Atopy is a personal and/or familial tendency, usually in childhood or adolescence, to become
sensitized and produce IgE antibodies in response to ordinary exposure to allergens, usually proteins.
The production of specif ic IgE in response to exposure to common environmental allergens such as
pollens, animal dander or food. Atopy can also be defined as the presence of certain conditions such
as eczema, asthma, hay fever or food allergy.
Eczema
The umbrella ter m for a local inflammation of the skin should be dermatitis. What is generally known
as “atopic eczema/dermatitis” is not one, single disease but rather an aggregation of several diseases
with certain characteristics in common. A more appropriate term is eczema. The subgroup related to
allergic asthma and rhinoconjunctivitis, i.e. eczema in a person of the atopic constitution, should be
called atopic eczema. Close contact with low molecular–weight chemicals may provoke a
predominantly TH1 ly mphocyte mediated allergic contact dermatitis. The non-allergic variety can also
be described by terms like irritant/toxic
contact dermatitis.
Food allergy
An immune-mediated hypersensitivity reaction to food div ided into IgE (immediate onset) and non IgE
mediated (delayed onset) reactions.
Intolerance
A reaction to certain food ingredients/additives that enhance taste, add colour, or protect against the
growth of microbes.
Example 1:w hen lactase enzyme is missing, dietary lactose results in gas formation, which in turn
causes symptoms of bloating, abdominal pain, and sometimes diarrhoea.
Example 2: w hen the immune system responds abnormally to dietary gluten.
Example 3: histamine toxicity or scombroid food poisoning associated w ith fis h that is not refrigerated
properly.
This term no longer used. It refers to obsolete technology. The correct term is serum specif ic IgE
testing.
RAST
Rhinitis
Inflammation of the nasal mucosa may be allergic or non-allergic. Referred to rhinoconjunctiv itis when
also involving conjunctiv a. Characterised by 4 cardinal clinical features: Nasal discharge, bloc kage
itch and sneezing.
Urticaria
Urticaria is characterized by the sudden appearance of wheals and/or angioedema. A wheal consists
of three typical features:
1. A central swelling of variable size, almost invariably surrounded by a reflex erythema
2. Associated itching or, sometimes, burning sensation
3. A fleeting nature, w ith the skin returning to its normal appearance usually within 1–24 h
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 14
Food allergy: guidelines for diagnosis and management in Primary Care
9.
References
1. Atopic eczema in children CG 57: management of atopic eczema in children from birth up
to the age of 12 years. National Collaborating Centre for Women’s and Children’s Health.
National Institute for Health and Clinical Excellence (UK) 2007.
2. Irish Nutrition and Dietetic Institute: Food Allergy Management resources. www.indi.ie
3. Cont ained in IFA N Food Allergy Carepathways (2012):
A voiding milk,
A voiding egg
A voiding peanuts
A voiding tree nuts
4. Task Force on the allergic child at school (TA CS) position document, Muraro et al, EAACI
2009. The management of anaphylaxis in childhood Muraro et al EAACI 2007.
5. Food allergy in children and young people. Diagnosis and assessment of food allergy in
children and young people in primary care and community settings (CG 116). National
Institute for Health and Clinical Excellence (UK) 2010.
6. Royal College of Paediatrics and Childcare (UK) Allergy Care Pathways for Children.
Asthma/Rhinitis 2011.
7. The Global Initiative for Asthma. Guidelines and Resources: 2005 Update
8. British Thoracic Society Scottish Intercollegiate Guidelines Net work. British guideline on
the management of asthma. A national clinical guideline. Thorax 2003;58:i1–i94.
9. Managing Chronic Health Conditions at school.
A resource pack for teachers and
parents. Availabl e from Anaphylaxis Ireland. www.anaphylaxisireland.ie/
10. WAO/EAACI Allergy Definitions. EAACI Nomenclature Position Statement 2001.
11. Guidelines for the diagnosis and management of food allergy . Boyce at al, National
Institute for Allergy and Immunologic Diseases. 2010.
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
Page 15
Food allergy: guidelines for diagnosis and management in Primary Care
Appendix 1. Sample emergency management plan
©Irish Food Allergy Net work 2012.
Primary Care Algorit hm
9
Page 16