After a hugely successful live Q&As on Facebook and Twitter with top allergy consultant Dr George Du Toit, here are your top 7 allergy questions answered:
Question: We have been told our daughter, who is 11 weeks old, has a milk allergy. I am breast feeding and taking no dairy products myself. When can I start weaning her and at what age should I have her retested?
Answer: Most paediatric guidelines suggest first introducing single ingredient foods between 4 and 6 months of age, at a rate not faster than one new food every 3 or so days. I suggest you trust your 'gut instinct' and when she appears to be hungry despite adequate breast or hypo-allergenic milk intake (e.g. waking in night, hunger cries more frequent, following and grasping at foods...) then commence weaning. Typical weaning foods in the Western diet include rice or oat cereals, yellow/orange vegetables such as sweet potato, squash, and carrots, fruits, e.g. apples, pears, and bananas, green vegetables, and then additional foods such as meat and fish. Remember that it is common for acidic fruits, e.g. berries, tomatoes, citrus fruits, and vegetables to cause, upon contact with the skin, localized, perioral reactions that may include an erythematous rash or urticarial due to irritation from the acid in these foods and high levels of histamine releasing compounds within the foods, respectively. These do not usually result in systemic reactions; therefore, delayed introduction of these healthy foods is not recommended. Such foods will be best tolerated when cooked and if a thick emollient is applied to any dry skin or eczema on the checks. I do not suggest introducing other highly allergenic foods as one of the first weaning foods until allergy testing has been performed to ensure she is not allergic to these; however, once a few typical weaning solid foods are tolerated, and with negative tests to hand, highly allergenic foods may be introduced as weaning foods. The Food Standards Agency has details on other foods to be avoided in the first year for reasons other than allergy concerns; e.g. honey (risk of Botulism), certain fish species, under-cooked egg (risk of Salmonella), whole nuts (risk of choking).
Question: Can you please outline how we can avoid our children developing asthma.
Answer: The prevention of asthma is a poorly understood science, despite a huge amount of active research in this field, complicating this is that there are many subtypes of asthma. Whilst many children wheeze in early childhood only a small percentage will go on to develop persistent asthma. I suggest you have your child fully evaluated by an expert in this field, they will need to make a complete assessment after taking into consideration the family history, allergy status, past symptoms and responses to therapies to date. Immunotherapy may be an option if your child is allergic but there is certainly no magic bullet for the prevention of allergy.
Question: My son has developed symptoms during the summer of nasal congestion, sneezing and itchy red eyes. I believe that this is due to hay fever which is in the family. I was wondering if this is indeed due to hay fever and what treatment options are available for his pollen allergies?
Answer: The symptoms you describe and the seasonality are indeed suggestive of hayfever (allergic rhino-conjunctivitis). In allergic rhino-conjunctivitis it is the nose and eyes bear the brunt of the inflammatory reaction; this results in characteristic symptoms such as a blocked or runny nose, repetitive violent sneezing, intense itching of the nose and/or eyes, and a postnasal drip. Mouth breathing may result in dry teeth (associated with halitosis and poor dentition) and dry cracked lips, these may be licked repetitively resulting in a ‘lip licking’ eczema. Sleep patterns may also be disturbed; children with hay fever are frequently described as ‘restless sleepers’ as evidenced by chaotic bed linen in the morning. Hay fever can impact on schooling, particularly as exams are usually taken in the summer months. Rubbing of the nose may result in a clear line across the nose (called a nasal crease) and rubbing of the eyes may result in deep skin folds under the eye (called Morgan Denny’s folds); the dark areas under the eyes are called ‘allergic shiners’ - making the children appear fatigued. A post nasal drip may result in a dry hacking cough and ‘antisocial throat clearing noises’ that sometimes drive mothers crazy! Children with hay fever also blink repetitively and distort their itchy mid-facies sometimes resembling the ‘facial mannerisms of a rabbit’ or a ‘nervous tick’.
Different aero-allergens can cause hay fever at different times of the year. Tree pollens cause hay fever in spring i.e. Feb, March, April months and grasses are the biggest culprits during mid-summer from May to August. Weeds such as nettles and dock as well as mugwort and plantain can trigger hay fever in late summer and autumn. Birch and alder pollen sensitivity are particular problems for allergy sufferers in the UK (where Birch is increasingly popular); these allergies may also give rise to the Oral Allergy Syndrome with increasing age. The main fungal spore season is in late summer i.e. Sept-Nov. Hay fever is worse in the cities where the symptoms are compounded by pollution.
Your treatment options (besides allergen identification and avoidance) include the use of medications such as non-sedating antihistamine and intra-nasal steroid sprays. These will offer a fair degree of symptom control but in those with moderate-to-severe symptoms this will not reduce all symptoms. He will need to be shown the correct technique for taking an intranasal spray to optimise delivery and to reduce intranasal discomfort and nasal bleeding. Finally, the only potentially curative therapeutic option is immunotherapy. This entails the taking off commercial pollen extracts under his tongue for three years. This type of treatment enjoys an excellent safety profile. Children do however need to be motivated and slightly older to tolerate this as once the product is placed under your tongue they will need to be quiet for a minute or two before swallowing. In my experience children can generally tolerate this from around six years of age. Immunotherapy is sometimes difficult to come by but there are NHS Trusts that offer this (see the BSACI website for details of clinics in the UK) and the allergic consultants at The Portland certainly do offer this.
Question: My young daughter has severe atopic eczema. I have heard that there is a chickenpox vaccine? I am interested in this and was wondering what your thoughts on this are?
Answer: The chickenpox vaccine is part of the routine immunisation schedule in many countries including Australia and America. It is not currently included in the UK DoH vaccine Schedule. In the UK the Chickenpox vaccine is recommended only to at-risk children and family members e.g. those who are immune-compromised due to chemotherapy… The chickenpox vaccine is also given to women who have been exposed during pregnancy and who are not immune as there is a risk to the developing baby. So, for all children outside of these ‘at-risk’ categories the chickenpox vaccine is not routinely indicated in the UK. However, I am in favor of this vaccine particularly in young children with eczema or for families who travel to countries where the vaccine is provided to local children. Chickenpox gives rise to intense itchy skin lesions and this is more troublesome for those with underlying eczema (itself an itchy condition). Indeed, in the presence of atopic eczema there may be an increased rate of complications such as skin infections and permanent scarring. The vaccine enjoys an extremely safe profile but requires two jabs to provide good cover in the UK. If you are interested in the vaccine and wish to read more about the long-term efficacy (it is a relatively new vaccine) and safety profiles the Wikipedia Website and the DoH websites are very helpful resources.
Question: My 14 year old complains of an itching sensation in his mouth and throat whenever he eats fruit. Is there anything I can do to help this? Other than this he is very healthy and I’m worried that he won’t be getting the vitamins he needs if he stops eating fruit.
Answer: It may be that he has now developed the Oral Allergy Syndrome (OAS); the OAS is caused by 'cross-reactivity' between proteins found in certain foods (fruit, vegetables and nuts) and pollen (usually birch and grass pollen). Birch pollen cross-reactivity may occur to one or more of the following foods; hazelnut, pitted fruit (apple, peach, pear, nectarine, apricot, and cherry) and carrot celery, and kiwifruit. Grass pollen cross-reactivity may occur to one or more of the following foods; melon, tomato, and orange. Importantly, no single patient will be allergic to all the above listed foods, grapes are usually the best tolerated! The responsible proteins are ‘heat labile’ so the troublesome food will usually be tolerated when eaten ‘cooked’ e.g. as canned peaches or apple tart or fruit juice. Additional factors that influence allergenicity of the fruit include; ripeness, fruit type, and time spent refrigerated. Peeling of apple also reduces the allergen load for apple as much of the allergen resides in the peel. OAS symptoms are most prevalent during the associated pollen season. Symptoms will be milder than 'classic' food allergy' symptoms and are usually restricted to the mouth and pharynx e.g. tingling and a metallic taste. Severe reactions are rare. This is a very frustrating condition for parents to deal with as the children with the OAS typically enjoyed these healthy foods when younger and now either dislike them or eat them only when cooked or processed e.g. fruit juice.
Question: I think my child is kiwi fruit allergic, should I avoid other fruit?
Answer: Kiwi fruit allergy is a relatively common food allergy in childhood. Reactions are usually mild but can be severe. If your child is allergic to green kiwi the please avoid 'golden' kiwis as well as the allergens are very similar. Kiwi also shares allergens with foods such as banana, avocado, latex. if these have been eaten and tolerated by your child then please continue eating, if they have a strong dislike/aversion for same, then avoid until allergy testing undertaken. Cross reactivity with other fruits such as dragon, star, passion fruit, has not been well defined but best to perform allergy testing to these before introduction.
Question: My child has twice experienced an allergic reaction after eating scrambled eggs. He eats egg in cakes and biscuits! How can this be, is he really egg allergic?
Answer: The allergens in egg and milk protein are complex allergens, which are made up of amino acids in long ‘strands’. These ‘strands’ are folded into special structures; these structures are heat labile i.e. intense heating of milk and egg disrupts the shape of these structures. Highly egg-allergic children will therefore react even to baked egg as they recognise not only the special allergen structures but also the loose strands. However, many egg allergic children – like your son – recognise only the loose strands; indeed up to 60% to 70% of children who react when eating regular cooked egg foods e.g. scrambled egg will be able tolerate egg in baked foods e.g. fairy cake. There is an increasing body of evidence to suggest that if baked forms of foods are tolerated then it is a good idea to keep this up in the diet in order to 'hurry up' the process of developing tolerance to all egg proteins. The same argument holds true for milk. This is not the case with peanut where intense heat processing of peanut renders peanut more, not less, allergenic. Nonetheless, any such introductory program should take place under the care of specialist allergist. I hope this answers your question.
Question: My son is 5 and he has a nut allergy and has been advised to carry around an adrenaline device. I’ve heard that he should be carrying two. Is this correct?
Answer: Thank you for posting this important question. The Allergy Specialists at the Portland Hospital follow the recommendations of the major Allergy Societies that two adrenaline auto injectors (AAI) devices should be available to nut allergic patients at all times. However, this gives rise to logistic concerns. For example, should there be two separate AAI's at the grandparent’s home and at school as well as two on the person (requiring the provision of 6 AAI's). As each circumstance varies it is very hard to dictate on this but i feel strongly that two AAI's must be readily available at all times. This is particularly so when eating out, undertaking travel, or when in remote areas where urgent medical care will not easily be accessible. Severe allergic reactions occur soon after exposure, typically within 10-20 minutes after exposure. The reason for 2 AAI's is that one may not be enough to deal with more severe reactions but also that the administration of the first AAI is not always performed correctly (despite adequate training) which is understandable given that the patient will by definition be extremely unwell and the person administering the device will be nervous. I hope this answers your question.
Question: My daughter is 6 years old and was diagnosed with peanut allergy after a reaction when she was 4. No other allergies have come to light but she avoids all nuts. This worries us terribly and gives rise to so many questions. What are the chances she will experience a severe reaction in the future? Will she outgrow this? Can she eat other nuts and what about products that 'may contain nuts’ Thanks.
Answer: A diagnosis of peanut allergy has been shown to be associated with significant parental stress and the questions you ask are shared by the many other 'allergic families'.
Peanut allergy is generally a life-long persistent food allergy, only 15-20% of children will outgrow peanut allergy. This opposite is true for egg and milk which are generally considered 'childhood allergies' and outgrown by most children by school entry; Favourable prognostic factors for outgrowing peanut allergy include; previous mild reactions, allergy to just one nut, and low allergy test results (using either prick test or blood IgE allergy tests. When peanut allergy is outgrown this usually takes place by five years of age. The fact that your daughter is now six years of age and still has on-going reactivity to peanut decreases the chance that she will outgrow this allergy.
With regards to living with peanut allergy over time, currently the only available treatment modalities remain that of strict avoidance and the early recognition and appropriate treatment of accidental allergic reactions. Emergency treatments include non-sedating antihistamines for very mild symptoms and for moderate-to-severe symptoms, intramuscular Adrenaline. Children with asthma will also need to carry their inhalers and an emergency dose of oral prednisolone. It is important therefore that your family is trained and skilled to provide such medications and that she has a personalised emergency plan issued. It is very important that the medications and emergency plan accompany your child. Reassuringly, the vast majority of nut-induced allergic reactions are mild-moderate in severity but severe anaphylactic reactions are possible (risk factors include, previous skin contact reactions, increasing age > 5yrs of age, diagnosis of wheezing/asthma).
There is a lot of educational support available to you through the larger allergy charities in the UK such as Allergy UK and the UK Anaphylaxis Campaign. The latter also run camps educational events for allergic children.
Remember that nut-induced allergic reactions usually arise due to nuts being eaten in unfamiliar foods (usually provided, accidentally, by an adult). Please teach your daughter to recognise different nuts and typical nut-containing foods e.g. peanut in snickers bars and crunchy nut cornflakes, pine (and increasingly cashew) in pesto sauce, hazel in chocolate spread, and almond in marzipan. Indian, Chinese and South Asian cuisines frequently contain peanut and cashew nut. The naming of any one specific nut may vary e.g. peanut may be labelled as ground nut, monkey nut, or Arachis. Bird and animal feeds often contain peanut.
The ‘may contain’ and ‘made in a plant’ labels are a great stress to nut allergic families as they are not an absolute guarantee that the food does or doesn’t contain nut/s. These labels will be found on the vast majority of EU processed foods; there are moves underway to improve the labelling but this is a complex task. Please sign up to the charities listed above, as they will issue product warnings when production mistakes are identified. If as a family you decide to include 'may contain' products in her diet then please eat familiar brands that you know she has previously tolerated and foods that intuitively do not seem to be at higher risk of containing nuts; unfamiliar ‘may contain’ products should initially be smeared on her arm, then lips, before cautiously tasting the food, this will increase the chance that she detects any hidden nut. She should be encouraged to trust her ‘nut detection instincts’ as this often proves correct i.e. early symptoms must be reported to a responsible adult, a process that is embarrassing with increasing age. Unlike for milk and fish, an allergic reaction due to the inhalation of nut protein is extremely rare. Whilst refined peanut nut oil may be safe for many peanut allergy children, crude nut oil is definitely not - it is safest therefore for her to avoid all nut-derived oils.
Sixty percent of peanut allergic children become allergic to other nuts (tree nuts) and/or sesame so it is worthwhile ensuring that all these allergies have been screened for (unless previously eaten and tolerated). If tests are negative then you may wish for her to continue eating safe nuts for her (as she won’t be allergic to every nut) but only under your supervision. However, some families prefer to strictly avoid all nuts, regardless of specific allergy profiles.
The prevalence of peanut allergy has doubled over the last decade. Around 2-3% of young children are now peanut allergic. The long-term outcome for her as she enters adulthood is not that well understood as the disease has not been around for that long. Our knowledge is however rapidly increasing as more Dr's undertake clinical research. There are many research projects underway looking at potential treatments and hopefully within the next decade or two there will be some effective safe treatment available for her.
For more information on allergies or to book and appointment with George Du Toit please call the Children's Services Enquiry Line on 020 7390 8020.