NICE has today (23 February) published the first evidence-based guideline on the diagnosis and assessment of food allergy in children and young people. Aiming to support GPs, nurses, healthcare professionals working in community/primary care and patients, it gives clear recommendations on the diagnosis and assessment of children and young people with suspected food allergy. It warns against the use of some alternative and high street testing.

Food allergies are adverse immune responses to food allergens[1]. They are among the most common allergic disorders and are recognised as a major paediatric health problem in western countries. Reactions can be extremely severe; hospital admissions in the UK for food allergies have increased by 500% since 1990[[2], and there has been a dramatic increase in prevalence in the last twenty years, ranging from 6% to 8% in children up to the age of 3 years across Europe and North America[3]. The most common foods to which children and young people are allergic include cow's milk; fish and shellfish; hen's eggs; peanuts, tree nuts and sesame; soy; wheat and kiwi fruit.

Food allergy in children can manifest itself in a range of symptoms, and so the guideline recommends that it should be considered if the child has one or a combination of the following, including:

• Skin conditions such as eczema or acute urticaria (itchy rash)
• Gastrointestinal problems such as vomiting, nausea or constipation
• Respiratory complaints such as sneezing, or shortness of breath
• Anaphylaxis (severe, hyper-sensitive reaction) and other allergic reactions.

Food allergy should also be considered in children who do not adequately respond to treatment for atopic (allergic) eczema, gastro-oesophageal reflux disease (where stomach contents flow out of the stomach and into the oesophagus [gullet]), and chronic constipation.

If a food allergy is suspected, the GP or other healthcare professional should take an allergy-focused clinical history, tailored to the presenting symptoms and age of the patient. This should include a family history of allergies, an assessment of the symptoms, details of any foods that are avoided and reasons why, and feeding history as an infant. A physical examination (dependent on the allergy-focused clinical history) should pay particular attention to growth, and physical signs of malnutrition.

The guideline also recommends offering the patient appropriate information based on the type of allergy suspected, the risk of severe allergic reaction, and the diagnostic process. This may include excluding specific foods from the diet and reintroducing these foods with reoccurrence of the allergic reaction confirming diagnosis. Diagnosis may also include skin prick and/or blood tests for IgE (immunoglobulin) antibodies because specific antibodies suggest particular allergic reactions. Alternative methods of diagnosis readily available on the high street or via the internet such as the Vega test [4], kinesiology[5], and hair analysis are not recommended. There is currently very little evidence to show that these tests work. Such alternative tests currently retail for up to £60.00 online, with high street testing costing significantly more.

This guideline has been produced to help provide consistency in the way that food allergy is diagnosed. Of those children who report an allergy, there are at present up to 20% who wrongly self-report diagnoses of various food allergies and do not eat certain foods because they think they are allergic to them, but have not had a confirmed diagnosis.[6]

Referral to secondary care should be considered if the child has ongoing problems including faltering growth, vomiting, abdominal pain, loose or frequent stools, or constipation, in combination with other gastrointestinal symptoms.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: “Food allergy in children is becoming increasingly common in the UK. This guideline identifies clear, evidence-based approaches to help healthcare professionals diagnose and assess this condition, which is often misunderstood because many of the symptoms are common to other complaints, and so it's not always easy to identify correctly. It is also the first guideline of its kind and will be a very helpful resource for both healthcare professionals and patients alike in improving outcomes for children affected by this condition.”

Dr Adam Fox, Consultant in Paediatric Allergy, Guy's and St Thomas' Hospital NHS Foundation Trust, London, and Guideline Development Group member, said: “We are seeing more and more children and young people being diagnosed with food allergy in the UK, so this guideline will be absolutely crucial in helping to diagnose and assess this condition, which can be both upsetting and frustrating for both children and their parents. Many parents often turn to alternative methods to help diagnose their child, but there is currently little evidence base for these approaches, and parents often end up putting their children on very extensive restriction diets following the inaccurate diagnosis, which can leave them malnourished, as well as wasting time and money.”

Mandy East, National Allergy Strategy Group and Anaphylaxis Campaign, and Patient / Carer representative, said: “As someone who has seen firsthand the sometimes distressing effects of food allergy, I am delighted to be involved in the first evidence-based clinical guideline for this condition. I am sure it will improve the care and outcomes for children and young people with suspected food allergy, as well as assisting those healthcare professionals involved in diagnosis and assessment.”

View the final guidelinefor further information.

Ends

Notes to Editors

About the guidance

1. The final guideline is available from Wednesday 23 February on the NICE website at: cg116

2. This guideline does not cover children and young people with food intolerances, such as intolerance to lactose.

3. This guideline covers children and young people from 0 years up to their 19^th birthday.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients.

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

Footnotes

[1] A substance that causes an allergy.

[2] Gupta R, Sheikh A, Strachan DP, Anderson HR (2007). Time Trends in Allergic Disorders in the UK.

[3] NICE clinical guideline - Diagnosis and assessment of food allergy in children and young people in primary care and community settings.

[4] An electrodermal test which involves measuring electromagnetic conductivity in the body.

5] Muscle testing.

[6] Allergy 2009. Review article. Factors influencing the incidence and prevalence of food allergy. Cochrane et al, Allergy 2007. Review article. The prevalence, cost and basis of food allergy across Europe. Mills et al, JAMA 2010; 303(18):1848-1856. Diagnosing and Managing Common Food Allergies: A Systematic Review Schneider Chafen et al, Journal of Allergy Clinical Immunology 2008; 121:1331-1336. Epidemiologic risks for food allergy. Lack G

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