Features

Eating with caution

07 December 2018

With childhood food allergies on the rise, you can play an important part in keeping children safe. Journalist Georgina Wintersgill reports.

The tragic case of 15-year-old Natasha Ednan-Laperouse, who died of an anaphylactic reaction after eating a Pret a Manger baguette, has highlighted just how serious food allergies can be (Siddique, 2018).

Natasha, who had multiple severe food allergies, died in July 2016 after eating an ‘artisan’ baguette containing sesame. A second Pret customer, who died in 2017, is believed to have suffered an allergic reaction to a flatbread product containing dairy, the chain has said.

Death from anaphylaxis-related food reactions are, thankfully, rare – there are around 10 such deaths in England and Wales each year (NHS, 2016).

However, food allergy is common: in the UK, around 5% to 8% of children suffer, compared to 1% to 2% of adults (Food Standards Agency (FSA), 2016a).

According to the charity Anaphylaxis Campaign, the greater prevalence of food allergies in children is likely to be related to the fact that most children outgrow their allergies. This is particularly true of cow’s milk, wheat and egg (although for a few children, allergies to these foods can persist). However, only around 20% of children with a peanut allergy outgrow it, while just 9% of children with tree nut allergies outgrow them (Anaphylaxis Campaign, 2017).

What’s more, food allergies appear to be on a continual rise. Research on the prevalence of peanut allergy in children found that, in 2002, around one in 70 children across the UK suffered, compared with just one in 200 a decade before (Anaphylaxis Campaign, 2018).

And in 2014, NHS hospital admissions for allergies increased by nearly 8% in a year in England, according to figures from the Health and Social Care Information Centre (HSCIC). The rate was highest in children aged 0 to 4 and generally decreased with age (NHS Digital, 2014).

Another study found an increase in hospital admission rates (but not deaths) due to anaphylaxis in England and Wales over a 20-year period (Turner et al, 2015).

The hypotheses

The reason for the rise in food allergies isn’t yet understood, although there are many theories. One is that our clean, modern lives have reduced the number of germs the immune system has to deal with, causing it to overreact when it comes into contact with harmless substances.

‘There are various hypotheses, none of which absolutely explain the modern-day epidemic of food allergies,’ says Dr George du Toit, professor of paediatric allergy at Evelina London Children’s Hospital and King’s College Hospital and consultant at the Portland Hospital. ‘The long-standing hypothesis is the hygiene hypothesis, which imagines that many factors associated with modern, clean, industrialised living – for example, smaller families, lots of antibiotics, vaccines, caesarean sections, pollution and processed food – may have partly been associated with the rise in food allergies.’

Nicole Rothband, specialist paediatric dietitian and spokesperson for the British Dietetic Association (BDA), says that low breastfeeding rates may also be a contributing factor. She says: ‘Children are exposed to cow’s milk protein a lot earlier in the form of formula milk. Even when mums are intending to breastfeed, if their child is born with low blood sugar they’ll be given formula in hospital and that can sensitise a child to cow’s milk protein, particularly if they’ve been born by caesarean and perhaps the mum’s been given antibiotics during labour. These are all factors that can contribute to an increased risk.’


2%-3% of children living in the developed world suffer from cow’s milk allergy, making it the most common cause of food allergy in the paediatric population. The prevalence is lower among breastfed infants (0.5%) - Lifschitz, 2015


Reducing the risk

So is it actually possible to help prevent food allergies developing in the first place? Most food allergies affect children under the age of three, according to the NHS (2016). Certain children are known to be at higher risk, including those with an existing food allergy or those with eczema (see Eczema: soothing soreness, page 22).

Dr du Toit says: ‘Risk factors for food allergy include early-onset troubling eczema. When your skin is porous and leaky, if an allergen is exposed onto the skin, in the absence of eating it, you’re more likely to develop an allergy.’

He believes that CPs such as health visitors could help reduce the risk of a food allergy developing by helping parents manage their child’s eczema. ‘They need to do that as early on in life as possible. The longer and more severe the eczema, the greater the risk of developing a food allergy and other allergic conditions as well, such as asthma and hay fever when older.’

Weaning practices could also influence food allergy. One UK study found that factors with a protective effect included continued feeding of breastmilk while introducing solids, simultaneous feeding of breastmilk and cows’ milk formula, a high diversity of diet, and following the infant-feeding guidelines. These included eating a variety of home-cooked foods containing plenty of fruit and vegetables, eating fish, and consuming fewer crisps, potato products and commercial baby foods (FSA, 2016b).

But confusion still exists among clients and healthcare professionals regarding the early introduction of solid foods to reduce the risk of allergies. In the past, common food allergens were excluded in early childhood. However, research such as the LEAP study (‘Learning Early About Peanut Allergy’, 2015) found that regularly exposing high-risk infants to food allergens had a protective effect. This excludes allergens an infant is known to be allergic to. Dr du Toit says: ‘We now know that early exposure to food allergens, at least to peanut and egg, confers a significant degree of protection for most infants. It’s a very important strategy, particularly for those at increased risk of developing food allergy, such as young children with eczema and/or existing food allergy such as egg allergy. It may appear counter-intuitive to some families, but it is a better approach. Through avoidance, you may increase or just defer the risk.’

The studies have led to changes in recommendations for preventing food allergy in higher-risk infants by the BDA and the British Society for Allergy and Clinical Immunology (BSACI). Their recommendation is that parents of infants with a known risk factor for food allergy should consider introducing solid foods – including cooked egg and then peanut – from four months, followed by other allergenic foods.

For infants with no risk factors for food allergy, the recommendation is to introduce solid foods, including peanut and egg, at around six months. The Department of Health and Social Care’s recommendations, however, differ for babies with a family history of eczema or food allergies (or asthma or hay fever), which state that those infants should be exclusively breastfed for the first six months and high allergenic foods shouldn’t be introduced before six months. They also say that parents of babies at higher risk of peanut allergy should speak to their health visitor or GP before introducing peanuts for the first time (NHS, 2018).

Nicole says what’s important for HVs is ‘to have an awareness that early introduction of cooked egg and then peanut may be protective’, and to ‘support them, not dissuade them if early introduction is something parents are keen to do – especially important if introduction of egg and/or peanut has started, as these foods need to remain to maintain tolerance. If HVs are unsure how to advise parents, they should contact their local paediatric dietetic service.’


1 in 5 children with early-onset eczema develop peanut allergy by age five - Du Toit et al, 2015

 


Helping families to navigate

Although preventative measures may reduce the risk (by how much is currently unknown), a food allergy may still develop. And for the 5% to 8% of children in the UK with food allergies, support is vital.

As many children with allergies are diagnosed and treated in the community (rather than being seen in allergy clinics), CPs may play an important part in helping parents understand allergy management techniques, including avoiding exposure to the allergen, recognising allergy symptoms and treatment.

Holly Shaw, nurse adviser to the charity Allergy UK, recommends using an allergy action plan for families. She says: ‘That way, the parents have a documented guide on what they should be doing, signs and symptoms to look out for and when to administer medicines. The gold standard is the Royal College of Paediatrics and Child Health (RCPCH) and the British Society for Allergy and Clinical Immunology (BSHCI) paediatric allergy action plan available on our website [see here]. It’s accessible for all of the UK, although locally certain allergy departments may have their own.’

Treatment watch

Nicole says: ‘The most important thing is to keep children safe. It’s really important if you encounter a child with food allergy to help them and their families understand the importance of avoiding exposure to whatever food they’re allergic to, always carrying their rescue medication and checking it’s in date.’

She adds: ‘In my clinics, I’ve encountered many families whose child has been prescribed an AAI (adrenaline auto-injector) and when I ask where it is, they say it’s in the car. It’s absolutely useless there.’

This year, those with severe allergies have faced added stress due to a shortage of EpiPens after manufacturing issues. The company has said that supply is expected to stabilise by the end of the year (EpiPen, 2018).

Anyone affected is advised to speak to their GP about using an alternative device – though the shortage has had a knock-on effect on the supplies of other brands.

The crisis has prompted the Medicines and Healthcare products Regulatory Agency to approve the use of nine specific batch numbers of EpiPen 0.3mg auto-injector devices beyond the labelled expiry date by four months. See epipen.co.uk for the affected lot numbers.

Translating labels

Learning to read food labels is key in avoiding allergens, but the death of Natasha Ednan-Laperouse highlights how difficult this can be.

The inquest heard that Natasha’s baguette did not have any allergen information on its wrapper, and this was within regulations: it was sufficient for signs to be posted around the store, telling customers with allergies to consult the store’s allergen guide or speak to a manager for advice (Siddique, 2018).

That’s because the UK’s Food Information Regulations 2014 say that freshly handmade, non-pre-packaged food does not have to be individually labelled (HMSO, 2014).

Although EU regulations state that any ingredient or processing aid causing one of the 14 main food allergies must be declared (Official Journal of the European Union, 2011), individual member states are responsible for deciding how information about non-pre-packaged food is given to the customer.

Nicole says that reading and understanding food labels is vital for families with allergies: ‘When eating outside the home, it’s important to be absolutely certain that they know exactly what they’re eating. You can only be reassured by the presence of a complete list of ingredients that states all allergens. If that’s not present, you can’t make an informed choice and therefore you should avoid.’

Unfortunately, labels can be remarkably unhelpful. For example, it seems more companies now put ‘may contain’ caveats on food labels in case of allergen cross-contamination. The FSA (2017) say that this precautionary labelling ‘should only be used following a thorough risk assessment when the risk of allergen cross-contamination is real and cannot be removed’. But Nicole says some manufacturers are doing this ‘in a kind of defensive move to protect themselves from any legal repercussions, which is unhelpful to allergy sufferers’. She emphasises: ‘If there’s any doubt at all, parents have to err on the side of caution.’ Of course, this can make all kinds of everyday situations stressful (see A parent's view, below).

What is stated is that ‘food must be safe to eat and information to help people with allergies make safe choices, and manage their condition effectively, must be provided’ (FSA, 2018).

For further advice, children can be referred to an allergy specialist who can give individually tailored advice.

Best practice

Nicky Forrest, a nurse with a background in health visiting and school nursing, runs a support group in Glasgow for parents of children with food allergies in conjunction with Anaphylaxis Campaign. She asked group members how CPs could best support parents in the same situation.

They said they would like CPs to signpost families to charities and support groups. Nicky says: ‘A lot of people don’t get signposted to other agencies that can help, but charities such as Anaphylaxis Campaign can provide support, literature and resources for training.’

The group felt that CPs and other related health professionals need a good understanding of the impact of diagnosis on children and families – both practical and emotional. Nicky says: ‘The impact is huge. The parent’s anxiety tends to rise every time they feed their child, certainly in the early days. They can also struggle to get childcare at nursery level and a lot of the time one parent ends up giving up work.’

She adds: ‘Diagnosis isn’t always a straightforward process. If they’re struggling to pinpoint the allergy, you’ll be referred to the allergy clinic but it won’t be immediate. There will be a period of time when the family is at home and struggling and CPs may be their only point of contact. Support is a big part of the CP’s role at that time.’

The group also felt that a good understanding of allergy as a whole is needed, recognising that many children have multiple allergies with co-existing conditions such as eczema, rhinitis and chest wheeze. ‘Making the link between different atopic conditions is quite important,’ she says. ‘If they [CPs]can start joining up the dots between the different allergic conditions, they are in the best position to help that family and they can make a big difference.’

The role of School nurses

Education is key: ‘Some people assume it’s a pseudo allergy,’ says nicky, whose seven-year-old daughter is allergic to tree nuts and eggs. ‘With all the faddy diets around, they think you’re just making life difficult for them.’

Holly, who advises Allergy UK, says: ‘School nurses have a key role to play in raising awareness and providing education and support to all staff and pupils. We need the whole school to be aware of allergies. Everyone should know they should wash their hands before and after meal times, and which children in the school have food allergies.’

School nurses should make sure that the child has an allergy action plan with their allergy clearly documented, and that staff are trained to recognise the symptoms – it’s not enough just to know where the EpiPen is kept. Small children need safeguarding, but as they get older they can take more ownership of their allergy, especially as they move into secondary school.’

Tricia Everett is a school nurse who works in a private school in Oxfordshire for children aged three to 18. At the start of each term, with consent, she updates a list with details of pupils’ allergies and circulates it to all relevant areas of the school, including the kitchen, food room and reception.

She says: ‘Each child with a severe allergy carries an EpiPen around with them – in the junior school they have a little bag to carry it in. There is a recent (2017) directive from the government [see here] saying schools can buy AAIs without a prescription to use in an emergency, so I keep two spare EpiPens in my health centre just in case, and one in the main reception.

‘All staff in the junior school have a first aid certificate, are trained in recognising symptoms of allergy and are trained to deliver the EpiPen. The staff who are trained in the senior school are the ones who might come into contact more often with a child with an allergy.’

The experience of Nicky Forrest’s support group in Glasgow is very different. ‘In our area, there’s a lack of training for education staff in schools and this is a big issue for the group,’ she says. ‘School nurses have been pulled out of EpiPen training in education this year, so as a parent you’re putting your child into an environment where training is non-existent, and that’s a real emotional struggle. If school nurses have the ability to go in and do some education with care providers, that will make a huge difference. The more people understand, the easier it is to recognise the signs of anaphylaxis and promptly deal with it.’ Of course, lack of funding is likely to play a part in this.

While allergy training for CPs isn’t routine in every area, every expert we spoke to felt it should be. A need for improved training and awareness all round is the main message.

Nicky, whose seven-year-old daughter Isla is allergic to tree nuts and eggs, says that education is key, as there is still a lack of public understanding around food allergy. ‘Some people assume it’s a pseudo allergy,’ she says. ‘With all the faddy diets around, they think you’re just making life difficult for them. Other people think it’s their human right to eat nuts wherever they want.

‘It is getting better, though, and the more it’s talked about, the better it will be.’


A parent's view

Sophie Bishop, 44, has a five-year-old son with allergies to milk, egg, sesame and peanut. Here, she provides an insight into some of the difficulties of navigating everyday life with a child with a severe food allergy.

Time is one of the biggest challenges, she says, as everything takes so much longer. ‘Food shopping is extremely labour-intensive and time-consuming,’ says Sophie. ‘I have to read every label, and I go to an average of three shops per week just to complete my weekly shop, because not all our safe brands are available in one place. Then there’s the time needed to cook almost all food from scratch.’ She points out that ‘free-from’ foods and buying specific ingredients are an additional expense for families.

Sophie admits that she misses the opportunity to be spontaneous: ‘We cannot be, due to always having to plan how long we are going to be out for, and how many meals and snacks are needed.’

Being constantly alert for potential allergens is another stressor, she says.

‘We have to maintain constant vigilance everywhere we go: playgrounds, play centres, cafes, people’s houses, other children – what they’re eating, what’s been dropped on the floor, what’s on their hands. ‘It’s exhausting.’


Resources

  • Read the new guidance on preventing food allergy in higher-risk infants by the BDA and the BSACI at bit.ly/BDA_BSACI_allergy
  • Anaphylaxis Campaign has factsheets and information online, plus details of conference, events and AllergyWise courses, including free ones for families at anaphylaxis.org.uk
  • Allergy UK has a section online for healthcare professionals including research and guidelines, details of training grants, CPD classes, and events. Go to allergyuk.org/health-professionals

 

References 

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