Some notes on the presentations

Lynne Regent, CEO of the Anaphylaxis Campaign, opened their health professionals' conference with a run down on the excellent work that the campaign does both in supporting allergy sufferers and in working with the food industry to improve safety, labelling and choice for allergic consumers. For more on both see the Campaign's website and especially the section on the food industry.

She then handed over to Debbie Hall, a registered nurse who has worked at Wellington College in Crowthorne for the last six years, caring for, among the 1,050 other pupils, 23 severely allergic children who react severally, to nuts, seeds, dairy, fruit, latex and insect bites. It is certainly a tribute to Debbie's care and instruction – as well as to the detailed allergy provision made by the school's caterers, Sodexo – that in six years they have not had a serious reaction.

Debbie described their protocols, which included:

• Detailed information provided by parents and guardians of allergic children entered on college database along with individual care plans for each child attached to their photo.
• Each child carries their own injector pen but extra generic pens are available all over the school and most of the staff have been trained to use them.
• The caterers have details and photographs of each allergic child and they meet each child to discuss his/her diet at least once a year.
• Pupils are encouraged to take responsibility for their own care and to tell their friends and educate them in allergy management.
• The school has a nut aware policy and aims for a nut free environment but nuts are not banned in the boarding houses.

An interesting presentation at the end of the day by Dr Rebecca Knibb, Senior Lecturer in the School of Life and Health Sciences at Aston University gave a slightly less reassuring slant on allergy provision in school – even though records show that serious food allergy reactions in schools are, in fact, very rare and getting rarer. As Dr Andrew Clarke pointed out earlier in the day, while in 2005 10% of allergic reactions to nuts took place in a school context, in 2009 only 4% did so.

Dr Knibb and her team have just completed some detailed research on allergy awareness in primary schools in the Midlands running from 2008 to 2012. They targeted 50 primary schools, sending detailed questionnaires to all staff and parents. 150 teachers responded as follows:

• 36% of teachers reported having an allergic child in the school; 23% did not know there was an allergic child in the school; only 4% had had to deal with an allergic reaction.
• 90% said they knew what food allergy was but, from the answers to further questions, in fact 30% did not know and 40% only had a very sketchy knowledge.
• 89% said they knew what anaphylaxis was but in fact only 22% really did.
• Only one teacher knew the difference between allergy and intolerance.
• 90% said they would know what to do in an emergency but in fact, 18% had no idea.
• 30% said they would call 999; 20% said they would give antihistamine; 30% would use an Epipen. Not one would give an Epipen and then call an ambulance, which is the correct procedure.
• 80% said they knew about management plans but very few really understood anything about them.
• Only 60% knew about Epipens; only 50% knew where they were to be found.
• 50% had had some allergy training; 58% had had some Epipen training. This training had all been either by a school nurse or by the parents of allergic children.

Among the 59 parents who responded:
• 50% of the respondents knew that the school had a management plan.
• 40% had been consulted about the plan.
• 47% were confident that the school followed the plans.
• 80% had talked to the school about their child's allergy.
• 90% were satisfied that their child's allergy was properly managed.

Prescription of injector pens, and generic injector pens.

In the context of these two presentations there were a number of questions from the floor about the prescribing of generic injector pens.

Adrenaline/epinephrine is a drug and drugs are normally only prescribed for individual patients so some primary care practices are reluctant to prescribe generic pens to be held by a school or other organisation for use on any child or patient who needs them.

Various ways around this (having two pens prescribed for an individual and using one as generic, having them prescribed for emergency use as with asthma and epilepsy medication) were discussed.

It was also pointed out that GPs often prescribe injector pens to patients who they suspect to be allergic but do not necessarily refer them to an allergy clinic so these patients may never have been properly assessed or had any ongoing testing.

Marks and Spencer, who were sponsoring the conference, gave an interesting and detailed description of their rigorous protocols for managing allergens within their factories (or their suppliers' factories) and explained the thinking behind their very comprehensive allergen labelling.

They were followed by three medical presentations from Dr Andrew Clarke, Carina Venter and Dr Claudia Gore.

Dr Clarke, who is a consultant in paediatric allergy at Addenbrooke's Hospital in Cambridge suggested that the figures for food allergy mortality did not really justify the very significant quality of life effects that the fear of food allergy had on many families.

For example, of the 89 deaths from anaphylaxis in Florida between 1996 and 2005, only 16% were as a result of food allergy the rest being from drug allergy (50%) and from venom allergy (20%). Indeed, of every 10 million deaths, only 5 could be attributed to food anaphylaxis.

He also pointed out that compared to drug or venom allergy (both much more common in adults than in children), food allergy was relatively slow to develop. With venom allergy collapse came within minutes, with drug allergy (very often on the operating table) it was almost instantaneous but with food allergy it would normally develop over 20 minutes to an hour working through facial and oral swelling, then abdominal pain, then wheeze and then collapse.

At Addenbrookes they are currently trying to establish the amount of peanut needed to trigger a reaction and it would seem that while 5mg may provoke a mucosal itch, there will be few more dramatic symptoms, whereas 50–100mg will normally provoke more serious symptoms.

However, the severity of the symptoms may depend on a number of other factors such as the patient's general health, their stress levels (as a result of anxiety, sleep deprivation etc) or extrinsic factors such as whether or not they are taking exercise at the time, or very close to the time, of ingestion of the allergen.

Dr Clarke pointed out that most atopic patients suffered from a number of allergies and intolerances and in management terms it was important to identify the most serious and focus management strategies on that. It was also important to identify the anaphylaxis trigger which may not always be just the food. In exercise-induced anaphylaxis, for example, it is the ingestion of the food very close to taking the exercise which causes a reaction which would not be triggered by either the food or the exercise alone.

He also pointed out that new patterns of reactions were continually emerging – such as red meat allergy. Here the patient appears to have been sensitised by the bite of a specific mosquito which shares a protein with red meat so that the first time that they eat red meat after being bitten they will react.

Carina Venter who is a specialist dietitian currently employed as NIHR Post Doctorate Research Fellow at the University of Portsmouth gave a very detailed presentation on the challenges presented by pre-school allergic children, a few of the highlights of which were:

• The importance of understanding the differences between immune mediated and non immune mediated food allergy/sensitivity.
• Understanding how a small child might describe a reaction so that precious time is not lost because the adult does not recognise what the child is describing. (See below.)
• Once a reaction starts there is no way of knowing how serious it will be so always take all food-induced reactions seriously.
• Nut policies.
a. Even though not all children are allergic to all nuts, and some children can tolerate cooked milk or egg but not raw, from a management perspective it is safer and easier to avoid all nuts, milk and egg in schools.
b. However, nut bans are not encouraged as they are difficult to enforce and give a false sense of security.
c. Having a 'no sharing of food' policy in schools is helpful, as is insisting that pupils remain seated while they eat as this makes it much easier for their separate food to remain separate.

How a child might describe an allergic reaction:

• Some children put their hands in their mouths or pull or scratch their tongues.
• Their voices may change, becoming hoarse or squeaky or they may speak very softly.
• They may suffer a sense of doom and think you are trying to kill them.
• They might say:
– It feels like there is a bump on the back of my tongue/throat.
– My mouth feels funny.
– The food feels spicy.
– My tongue feels full/heavy.
– My tongue feels as though there is hair on it.
– My tongue/mouth is hot/burning/tingling.
– It feels like there are bugs in my ears.
– It feels like something is poking my tongue.

Finally, Dr Claudia Gore, consultant paediatric allergist at St Mary's Hospital in London, talked about the difficult transition from childhood to adolescence/adulthood for an allergic person – from time spent with their parents to time spent with their peers.

She views an allergic adolescent as anyone between 10 and 24 years of age during which time, although many of them will outgrow their child allergies, many will not. At 18 roughly 18% will still have eczema, 16% rhinitis and 35% asthma.

During this time they will have to learn to manage their allergy on their own and she believes that this cannot start too early. Small children are far more aware than is often realised and from 5 onwards they should be involved in their allergy management; by the age of 10 they should be taking responsibility for their own medication.

Leaving home to go to university is always difficult but especially so as they need to transfer from paediatric care to adult. Moreover when they change GPs when they move to university there may be a 'data dump' from one practice to another without the receiving practice actually being aware of the history or what is in the notes.

Adolescents need to know:
• How to access healthcare – register with a GP, get prescriptions, medication etc
• Be aware that they have to pay for prescriptions – not cheap as allergics are currently not exempt from prescription charges.
• Be aware of the risks, especially of drinking and, if they have a food allergy, of kissing, sex etc.
• The impact their allergy may have, if not well managed, on their grades, future job prospects etc.

Injector pens and needle length.

During the lunch break there was some discussion about injector pens and needle length - please see the Foodsmatter blog here for more details.

For more on the Anaphylaxis Campaign and their work please check their website.

First published in October 2013

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