BSACI 2021 guideline for the management of egg allergy.

This guideline advises on the management of patients with egg allergy. Most commonly egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history will confirm the diagnosis in most cases. Investigation by measuring egg-specific IgE (by skin prick testing or specific IgE assay) is useful in moderate-severe cases or where there is diagnostic uncertainty. Following an acute allergic reaction, egg avoidance advice should be provided. Egg allergy usually resolves, and reintroduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive the MMR vaccine. Most adults and children with egg allergy can receive the influenza vaccine in primary care, unless they have had anaphylaxis to egg requiring intensive care support. Yellow Fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence based. Where evidence was lacking, consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.

Home-based cow's milk reintroduction using a milk ladder in children less than 3 years old with IgE-mediated cow's milk allergy.

BACKGROUND: The development of tolerance to cow's milk in allergic children is best determined by supervised baked milk exposure. Widely recommended hospital-based challenges can potentially delay contact because of resource limitations. OBJECTIVE: We sought to determine the efficacy and safety of our low-dose home-based reintroduction programme. METHODS: In our allergy service, children with IgE-mediated cow's milk allergy who met set criteria (presenting with skin and/or gastrointestinal symptoms only and skin prick test < 8 mm) are considered for home-based milk reintroduction (HMR). Early contact is low-dose ingestion of a commercial baked milk biscuit with slow gradual further exposure followed by increasing milk contact using a milk ladder. We retrospectively reviewed 4-6 monthly attendance records assessing allergic symptoms, evolving milk tolerance, and compliance. Tolerance was determined using a 7 scale scoring system based on the milk ladder. RESULTS: The clinic attendance and dietetic contact records of 86 children (49 girls) who underwent HMR were reviewed. HMR was started at a median of 13 months with 49% 8-12 months, 40% 13-18 months and 11% 19-33 months. Allergic symptoms were reported in 81 (43%) of 189 dietetic reviews, 65 (80%) of which were from the milk ladder; no patient experienced anaphylaxis requiring treatment with intramuscular adrenaline. After four reviews, only eight patients were not tolerating almost all dairy products, and there was a high rate of completion with only a further seven patients lost to the programme. CONCLUSION AND CLINICAL RELEVANCE: Cow's milk can be successfully and safely reintroduced in a cautious low-dose exclusively home-based programme in the appropriate clinical and family setting.

Single nut or total nut avoidance in nut allergic children: outcome of nut challenges to guide exclusion diets.

BACKGROUND: Children with diagnosed nut allergy are typically advised by health professionals to exclude all nuts from their diets, irrespective of the outcome of allergy testing, to avoid inadvertent contact through contamination or the possible development of new allergies. METHODS: In our service, as we feel greater diagnostic accuracy prevents dietary risk taking, we provide the facility for children with nut allergy the opportunity of controlled exposure to 'other' nuts irrespective of whether their allergy prick test (PT) results are positive or negative. We performed open food challenges on our paediatric day ward. The challenge food was administered by way of a homemade biscuit containing 8 g of each nut challenged and given in increasing visually measured doses. RESULTS: Over the 5-year period from 2006, we challenged 145 children diagnosed as peanut allergic or tree nut allergic. In those with peanut allergy challenged to tree nuts, none of the 72 with negative PTs to tree nuts reacted on challenge whilst 7 of 22 (31.2%) with positive PTs did. In patients with tree nut allergy challenged to peanuts and/or other tree nuts, 3 of 38 (7.9%) with negative PT results and 5 of 13 (38.4%) with positive PT results reacted. CONCLUSION: Children allergic to peanuts with negative allergy tests to tree nuts had no co-existing allergy, but were at risk of tree nut allergy where PTs were positive. Children with tree nut allergy were at risk of co-existing peanut or other tree nut allergy whether PTs were positive or negative. Oral challenges to clarify allergy status in all nuts show co-existing allergies even in young children and in so doing may reduce anxiety, minimize unnecessary dietary restrictions and prevent later episodes of anaphylaxis through uninformed exposure.