Quality statement 3: Diagnosing non‑IgE‑mediated food allergy

Quality statement

Children and young people whose allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy, and who have not had a severe delayed reaction, are offered a trial elimination of the suspected allergen and subsequent reintroduction.

Rationale

If an allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy, a trial elimination of a suspected allergen (followed by reintroduction) is important to confirm the diagnosis. Elimination of a food allergen may resolve or significantly improve symptoms and reintroduction may cause a recurrence or a further significant exacerbation. Elimination and reintroduction is not suitable for children and young people who have experienced severe delayed reactions; they should be referred to secondary or specialist care.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that children and young people whose allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy, and who have not had a severe delayed reaction, are offered a trial elimination of the suspected allergen and subsequent reintroduction.

Data source: Local data collection.

Process

Proportion of children and young people whose allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy, and who have not had a severe delayed reaction, who are offered a trial elimination of the suspected allergen and subsequent reintroduction.

Numerator – the number in the denominator who are offered a trial elimination of the suspected allergen and subsequent reintroduction.

Denominator – the number of children and young people whose allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy, and who have not had a severe delayed reaction.

Data source: Local data collection.

Outcome

a) Incidence of non‑IgE‑mediated food allergy.

Data source: Local data collection.

b) Children and young people with non‑IgE‑mediated food allergy who feel, or whose families feel, able to manage their condition.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (such as primary care providers) ensure that healthcare professionals offer a trial elimination of a suspected food allergen, with reintroduction after the trial, to children and young people if an allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy and they have not had a severe delayed reaction.

Healthcare professionals (such as GPs, primary care nurses, health visitors and paediatricians) offer a trial elimination of a suspected food allergen, with reintroduction after the trial, to children and young people if an allergy‑focused clinical history suggests a non‑IgE‑mediated food allergy and they have not had a severe delayed reaction. Healthcare professionals should have a good understanding of nutritional intake, timings of elimination and reintroduction, and follow‑up. Healthcare professionals offer children and young people (and their parents or carers if appropriate) information on:

  • what foods and drinks to avoid

  • how to interpret food labels

  • alternative sources of nutrition to ensure adequate nutritional intake

  • the safety and limitations of an elimination diet

  • the proposed duration of the elimination diet

  • when, where and how an oral food challenge or food reintroduction may be undertaken

  • the safety and limitations of oral food challenge or food reintroduction.

Commissioners (clinical commissioning groups and NHS England) commission services that offer trial elimination and reintroduction of allergens to children and young people if an allergy‑focused clinical history suggests non‑IgE‑mediated food allergy and they have not had a severe delayed reaction.

What the quality statement means for patients, service users and carers

Children and young people who are thought to have a food allergy that is not caused by IgE antibodiesare offered a trial of cutting out the food thought to cause the allergy (known as elimination) with introduction of the food again at a later date. This is to confirm the diagnosis.

Source guidance

Food allergy in under 19s: assessment and diagnosis (2011) NICE guideline CG116, recommendations 1.1.11 and 1.1.17

Definitions of terms used in this quality statement

Non‑IgE‑mediated food allergy

This is generally characterised by delayed reactions. Non‑IgE‑mediated reactions are poorly defined but are believed to be mediated by T‑cells. Signs and symptoms of non‑IgE‑mediated food allergy are given in recommendation 1.1.1 of the NICE guideline on food allergy in under 19s.

Trial elimination of the suspected allergen

Trial elimination of the suspected allergen would normally be for 2–6 weeks, followed by reintroduction. Advice should be sought from a dietitian with specialist training, about adequate nutritional intake, timings of elimination and reintroduction, and follow‑up. For people undergoing investigation for coeliac disease, see NICE's guideline on coeliac disease.

[Adapted from NICE's guideline on food allergy in under 19s, recommendation 1.1.11]

Advice on diagnosing non‑IgE‑mediated cows' milk allergy can be found in NICE's clinical knowledge summary on cows' milk protein allergy in children and the British Society for Allergy and Clinical Immunology's guidance on cow's milk allergy.

[Expert opinion]