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.

A meta-analysis of montelukast for recurrent wheeze in preschool children.

There is conflicting evidence of the effectiveness of montelukast in preschool wheeze. A recent Cochrane review focused on its use in viral-induced wheeze; however, such subgroups are unlikely to exist in real life and change with time, recently highlighted in an international consensus report. We have therefore sought to investigate the effectiveness of montelukast in all children with preschool wheeze (viral-induced and multiple-trigger wheeze). The PubMed, Cochrane Library, Ovid Medline and Ovid EMBASE were screened for randomised controlled trials (RCTs), examining the efficacy of montelukast compared with placebo in children with the recurrent preschool wheeze. The primary endpoint examined was frequency of wheezing episodes. Five trials containing 3960 patients with a preschool wheezing disorder were analysed. Meta-analyses of studies of intermittent montelukast showed no benefit in preventing episodes of wheeze (mean difference (MD) 0.07, 95% confidence interval (CI) -0.14 to 0.29; mean for montelukast 2.68 vs placebo 2.54 (p = 0.5)), reducing unscheduled medical attendances (MD -0.13, 95% CI -0.33 to 0.07; mean for montelukast 1.62 vs placebo 1.78 (p = 0.21)) and reducing oral corticosteroids (MD -0.06, 95% CI -0.16 to 0.02; mean for montelukast 0.35 vs placebo 0.36 (p = 0.25)). The pooled results of the continuous regimen showed no significant difference in the number of wheezing episodes between the montelukast and placebo groups (MD -0.40, 95% CI -1.00 to 0.19; mean for montelukast 2.05 vs placebo 2.37 (p = 0.18)). CONCLUSIONS: This review highlights that the currently available evidence does not support the use of montelukast in preschool children with recurrent wheeze. We recommend further studies to investigate if a 'montelukast responder' phenotype exists, and how these can be easily identified in the clinical setting. What is Known: • Current guidelines recommend montelukast use in preschool children with recurrent wheeze. • A recent Cochrane review has found montelukast to be ineffective at reducing courses of oral corticosteroids for viral-induced wheeze. What is New: • This meta-analysis has examined all children with preschool wheeze and found that montelukast was not effective at preventing wheezing episodes or reducing unscheduled medical attendances. • A specific montelukast responder phenotype may exist, but such patients should be sought in larger multicentre RCTs.

The RCPCH care pathway for children with drug allergies: an evidence and consensus based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the Department of Health to develop a drug allergy pathway. It focuses on defining the competences to improve the equity of care received by children. METHOD: The drug pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The team decided to focus on IgE-mediated reactions as these have the greatest potential to be life-threatening. RESULTS: The results are presented in four parts: evidence review, pathway mapping, external review and core knowledge documents. The evidence review found a high percentage of putative penicillin allergy is not confirmed by objective testing and that resensitisation to ß-lactam drugs was infrequent. It also highlighted the importance of a detailed history and accurate diagnosis along with clear communication of test results to both family and primary care. CONCLUSIONS: This pathway demonstrates the spectrum of drug allergy is varied and may differ for young children compared with older children and adults. The authors highlight the paucity of evidence to support allergy testing for most drugs, in children, other than supervised incremental provocation tests (when indicated). Acute presentations require emergency health professionals to address underlying allergic issues, including recognition and avoidance of potential drug allergy triggers. Non-acute presentations may include multi-system symptoms which may have a broad differential diagnosis; this document signposts to the relevant partners in the RCPCH care pathway portfolio. Management combines a care package including a definitive diagnosis, initiating treatments and ongoing education.

The RCPCH care pathway for children with latex allergies: an evidence- and consensus-based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the latex allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions. METHOD: The RCPCH latex allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. RESULTS: The results are presented in four parts, the evidence review, pathway mapping, external review and core knowledge documents. The evidence review highlighted the paucity of recent evidence for latex allergy in childhood. The review found that the diagnostic sensitivity of different latex extracts for skin-prick testing may differ. It also noted that health professionals should be aware of latex allergy, and care should be taken to avoid contact with latex in young infants, especially when there is a family history for latex allergy. The pathway entry points are defined by the severity at presentation. CONCLUSIONS: The latex allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patients home as possible. The authors recommend that this pathway is implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.

The RCPCH care pathway for children with venom allergies: an evidence and consensus based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science & Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the venom allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions. METHOD: The RCPCH venom allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. RESULTS: The pathway results are presented in four parts: evidence review, mapping, external review and core knowledge documents. The entry points are defined and the ideal pathway of care is described from self-care through to follow-up. The evidence highlighted that venom immunotherapy is safe and effective for bee and wasp allergy and that there are real quality of life benefits for patients. The review also highlighted the value of measuring serum tryptase after reactions. CONCLUSIONS: The venom allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible. The authors recommend that this pathway should be implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.