Community Nurses Can Reduce the Burden of Allergy
Introduction
Some 50 per cent of children in the UK have some form of allergy [1]. Infants with moderate/severe atopic eczema are likely to develop food allergy, asthma and rhinitis, known as the 'Allergic March' [2] (Figure 1). Such co-morbidities can fluctuate throughout life.
Health Visitors and community nurses are in a unique position to recognise infants with cow’s milk or other early food allergies. Up to 80 per cent of all children with moderate to severe eczema at less than one year of age are sensitised to one or more food allergens. It is increasingly recognised that infants with poorly controlled eczema are at increasing risk of faltering growth [3].
Food Allergy
Food allergy can be classified into IgE-mediated and non-IgE-mediated allergy. IgE-mediated reactions have a rapid onset. Non-IgE-mediated reactions are generally characterised by delayed and non-acute reactions [4].
IgE-mediated food allergy typically occurs in infancy, often concurrently or soon after atopic eczema (Figure 1). Symptoms are usually rapid and can affect the airway, skin, gastro-intestinal system or be systemic, causing anaphylaxis, which if not treated rapidly may be fatal. Clinical features may be:
- skin: pruritis, erythema, acute urticaria, acute angioedema around the lips, face and eyes
- gastro-intestinal: oral angioedema or pruritis, nausea, vomiting, abdominal pain, diarrhoea
- respiratory: Itching, sneezing, runny nose, congestion, cough, tight chest, wheeze, shortness of breath
- other: Conjunctivitis, panic, loss of consciousness
Non-IgE-mediated food allergy causes signs and symptoms that are also distressing and chronic. Eosinophilic Gastro-intestinal Disease (EGID) is still largely undiagnosed with huge impact on affected infants’ development and health.
Common symptoms are:
- gastro-oesophageal reflux, which causes crying, backache and vomiting after feeds
- abdominal pain; severe colic
- diarrhoea or constipation
- eczema
- aversion to foods
- faltering growth
Cow milk allergy
Cow milk allergy (CMA) is the most common food allergy in infants and young children [5], affecting between 2 - 7.5 per cent of infants [6], although 15 per cent may exhibit symptoms suggesting CMA at some time [5]. CMA causes both IgE and non-IgE-mediated reactions with some infants having both types of CMA.
It typically starts when the infant first has cows’ milk in formula feed, at weaning or via breast feeding. As well as unnecessary suffering for the child and distress to the family, these children present frequently to the General Practitioner (GP) and Health Visitor and will require ongoing future medical care. Nearly one in five (19 per cent) of parents visited their GP 10 times or more between presenting their child’s problems and diagnosis of CMA [7]. The MAP Guideline is a simple algorithmic guideline for diagnosis and management of CMA.
Diagnosis should be undertaken in a specialist allergy clinic where skin prick or blood tests are used in the diagnosis of IgE-mediated food allergy in conjunction with an allergy-focussed history. A specialist allergy dietician should support parents in managing the infant’s diet.
Those with non-IgE-mediated food allergy will, under dietary supervision, have the suspected food removed from the diet for an agreed period. Reintroduction and monitoring of symptoms will follow and if no improvement, the child must be referred to a paediatric allergist or paediatric gastro-enterologist. Diagnosis of Eosinophilic Gastrointestinal Disorder may require endoscopic examination.
Asthma and Rhino-conjuctivitis
80 per cent of children with asthma are allergic to one or more allergens [8] and allergen diagnosis and management can offer symptom reduction and improved quality of life.
The nose is the gateway to the lungs - it is one airway lined with continuous mucosa. 80 per cent with allergic asthma have rhinitis and 40 per cent with rhinitis have asthma symptoms. Seasonal (hayfever), intermittent or persistent allergic rhino-conjunctivitis causes irritation and inflammation of the nose, sinuses and conjunctiva due to one or a combination of allergens e.g. pollens, mould spores, house dust mite and pet allergens. ‘Summer asthma’ is usually the effect of inadequately treated seasonal allergic rhinitis.
Rhinosinusitis causes sneezing, itchy and blocked nose, congestion in the head, sinuses and ears and sometimes itchy ears and throat. The eyes become irritated or it could cause conjunctival oedema. It is often accompanied by asthma symptoms. Sleep disturbance affects concentration and causes irritability and lethargy. As well as the considerable morbidity caused by allergic disease, studies have shown that allergy symptoms impair examination results [9].
Atopic children often have the classic look of Dennie’s lines under the lower eyelid and darkening of the tissues under the eyes due to vascular congestion. They commonly display the ‘allergic salute’, unconsciously rubbing their noses upwards with the heel of the hand, sometimes with the resulting nasal crease. This mannerism is because of the constant nasal irritation.
Non-sedating antihistamines and a daily steroid nasal spray correctly used should alleviate the symptoms. Persistent symptoms despite treatment warrant allergy referral.
Although rare, Vernal Allergic Conjunctivitis and Vernal Kerato-conjunctivitis may most commonly affect young boys with potentially serious consequences. These present with large papillae on the tarsal conjunctiva or hypertrophy of the limbal conjunctiva. Punctuate keratitis may be present. Patients with these symptoms should have immediate specialist referral.
Normally antihistamine medicine and sodium cromoglycate drops or ointment should alleviate the symptoms. Wraparound sunglasses protect from strong light and pollen.
Further information for patients and professionals is available at: Allergy UK, or call the helpline: 01322 619898.