Recent NICE guidelines on the recognition and management of food
allergy in children and young people (1) stress the importance of the
allergy-focused history. The guidelines cite eczema, as one of several
clinical scenarios that should trigger the clinician to take such a
history, the rationale being that food allergy affects approximately 50%
of children with severe eczema compared to 8% in a general paediatric
population (2). The guidelines state that the allergy-focused history
should elicit: 1) the nature of the 'food reaction' (symptoms, cause,
reproducibility etc.) 2) presence or absence of an 'atopic diathesis'
(personal or family history of food allergy, eczema, allergic rhinitis or
asthma) and 3) a feeding history that includes recognition of failure to
thrive. Failure to ask these 3 questions represents a missed opportunity
to identify children with food allergy and attendant risks that include
exacerbation of asthma and anaphylaxis as well as worsening eczema.
In February 2010 as a medical student I audited the extent to which
general practitioners (n=11) based in a single center in the Greater
London area documented the presence of food allergy in children with
moderate-severe eczema. The medical notes of all children in the practice
under 5 years of age with moderate-severe eczema (defined as those
requiring repeat prescriptions of moderate or potent topical
corticosteroids, topical calcineurin inhibitors or bandages) were assessed
(17 children, mean age 3.6y). The presence or absence of a food reaction
was recorded in 0/17; presence/absence of an atopic diathesis was
documented in 4/17 and presence/absence of failure to thrive in 2/17
children. The findings were presented and discussed at the practice
meeting. One year later (February 2011) I returned to repeat the audit.
The corresponding assessments in 15 children were 1/15 for a food
reaction, 7/15 for atopic diathesis and 2/15 for failure to thrive. All
15 children had seen a doctor in the last year specifically about their
eczema and in none of them were all three questions asked.
These results identify a failure of the practitioners to consider
food allergy in children with eczema and a failure of presentation of the
results of a practice-based audit to improve the situation one year later.
A possible explanation is a lack of education, the absence until now of
clear guidance and conflicting advice from specialists regarding food
allergy. NICE guidelines on food allergy in children and young people
were unavailable at the time of this audit. However the 3 audit criteria
used closely mirrored the guidelines and therefore represent valid
choices. Hopefully the new guidelines will re-emphasise the importance of
an allergy focused history to identify those children with eczema at risk
of food allergy and in need of specialist referral.
(1) Sackeyfio A, Senthinathan A, Kandaswamy P, Barry P W, Baker M.
Diagnosis and assessment of food allergy in children and young people:
summarry of NICE guidance. BMJ 2011;342:d74
(2) Sohi D. Paediatric
allergies in primary care. GP 2010
Rapid Response:
Re:Food allergy in atopic eczema
Dear Editor,
Recent NICE guidelines on the recognition and management of food
allergy in children and young people (1) stress the importance of the
allergy-focused history. The guidelines cite eczema, as one of several
clinical scenarios that should trigger the clinician to take such a
history, the rationale being that food allergy affects approximately 50%
of children with severe eczema compared to 8% in a general paediatric
population (2). The guidelines state that the allergy-focused history
should elicit: 1) the nature of the 'food reaction' (symptoms, cause,
reproducibility etc.) 2) presence or absence of an 'atopic diathesis'
(personal or family history of food allergy, eczema, allergic rhinitis or
asthma) and 3) a feeding history that includes recognition of failure to
thrive. Failure to ask these 3 questions represents a missed opportunity
to identify children with food allergy and attendant risks that include
exacerbation of asthma and anaphylaxis as well as worsening eczema.
In February 2010 as a medical student I audited the extent to which
general practitioners (n=11) based in a single center in the Greater
London area documented the presence of food allergy in children with
moderate-severe eczema. The medical notes of all children in the practice
under 5 years of age with moderate-severe eczema (defined as those
requiring repeat prescriptions of moderate or potent topical
corticosteroids, topical calcineurin inhibitors or bandages) were assessed
(17 children, mean age 3.6y). The presence or absence of a food reaction
was recorded in 0/17; presence/absence of an atopic diathesis was
documented in 4/17 and presence/absence of failure to thrive in 2/17
children. The findings were presented and discussed at the practice
meeting. One year later (February 2011) I returned to repeat the audit.
The corresponding assessments in 15 children were 1/15 for a food
reaction, 7/15 for atopic diathesis and 2/15 for failure to thrive. All
15 children had seen a doctor in the last year specifically about their
eczema and in none of them were all three questions asked.
These results identify a failure of the practitioners to consider
food allergy in children with eczema and a failure of presentation of the
results of a practice-based audit to improve the situation one year later.
A possible explanation is a lack of education, the absence until now of
clear guidance and conflicting advice from specialists regarding food
allergy. NICE guidelines on food allergy in children and young people
were unavailable at the time of this audit. However the 3 audit criteria
used closely mirrored the guidelines and therefore represent valid
choices. Hopefully the new guidelines will re-emphasise the importance of
an allergy focused history to identify those children with eczema at risk
of food allergy and in need of specialist referral.
(1) Sackeyfio A, Senthinathan A, Kandaswamy P, Barry P W, Baker M.
Diagnosis and assessment of food allergy in children and young people:
summarry of NICE guidance. BMJ 2011;342:d74
(2) Sohi D. Paediatric
allergies in primary care. GP 2010
Competing interests: No competing interests