slide-set-powerpoint-136428589-health.ppt

Editor's Notes

• #1: ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on diagnosis and assessment of food allergy in children and young people in primary care and community settings. This guideline has been written for staff in primary care NHS settings, community settings, including the home environment and health visits, preschools, schools, children's centres and other childcare health settings, community pharmacy, community dietitian and community paediatric services. The guideline is available in a number of formats, including a quick reference guide. NICE recommends that you hand out copies of the quick reference guide at your presentation so that your audience can refer to it, as the slide set refers to information presented within the quick reference guide. See the end of the presentation for ordering details. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
• #2: NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the key areas for implementation. The key areas for implementation cover the following areas: Assessment and allergy-focused clinical history Diagnosis of IgE-mediated food allergy Diagnosis of non-IgE-mediated food allergy Providing information and support Referral to secondary or specialist care Alternative diagnostic tools Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE.
• #3: NOTES FOR PRESENTERS: Key points to raise: Food allergy can be classified into IgE-mediated and non-IgE-mediated reactions. IgE-mediated reactions are acute and frequently have a rapid onset. Non-IgE-mediated food allergy is frequently delayed in onset. Many non-IgE reactions are believed to be T-cell-mediated. Some reactions involve a mixture of both IgE and non-IgE responses and are classified as mixed IgE and non-IgE allergic reactions. Food intolerance is a non-immunological reaction that can be caused by enzyme deficiencies, pharmaceutical agents and naturally occurring substances. It is not covered in this guidance. Additional information The following are the most common foods to which children and young people are allergic: • cows' milk • fish • hens' eggs • kiwi fruit • peanuts • sesame • shellfish • soy • tree nuts • wheat. Less commonly, there are reported allergies to certain fruits, for instance, banana. Image: Image showing nut allergy lips reproduced with kind permission of Dr Pete Smith, Medicalpix.com
• #4: NOTES FOR PRESENTERS: Key points to raise: The prevalence of food allergy in Europe and North America has been reported to range from 6% to 8% in children up to the age of 3 years. There has been discrepancy between self-reported food allergy and confirmed correct diagnoses of food allergy. In view of this, there is inconsistency in the reported prevalence of food allergies in children and young people. Correct diagnosis of food allergy, followed by counselling and advice based on valid test results is important because it will help to reduce the incidence of adverse food reactions resulting from true food allergies and also help to prevent the unnecessary dietary exclusion of foods which are safe and which should be eaten as part of a normal, healthy diet.
• #5: NOTES FOR PRESENTERS: Key points to raise: The guidance covers those presenting with symptoms such as atopic eczema, anaphylaxis, urticaria, rhinitis, conjunctivitis, asthma, gastrointestinal symptoms and oral pruritus. Those at higher risk of developing food allergy include those with existing atopic diseases such as asthma, atopic eczema or allergic rhinitis, or alternatively a first-degree relative (parent or sibling) with a food allergy or other atopic disease. The guideline addresses six key clinical questions : What elements should be included in an allergy-focused clinical history? What tests should be used to diagnose IgE-mediated food allergy? What tests should be used to diagnose non-IgE-mediated allergy? What information should be provided during the diagnostic process? When should referrals to secondary and/or specialist care be made? What is the value of alternative diagnostic tests?
• #6: NOTES FOR PRESENTERS: Anaphylaxis A severe, life-threatening, generalised or systemic hypersensitivity reaction, characterised by rapidly developing life-threatening airway, breathing and/or circulation problems, usually associated with skin and mucosal changes. Food allergy An adverse immune response to a food. IgE-mediated reaction An allergic reaction which is acute and frequently has a rapid onset. Non-IgE-mediated reaction These reactions are generally characterised by delayed and non-acute reactions. Systemic allergic reaction An allergic reaction involving parts of the body distant to the actual site of allergen contact. Image: Image showing anaphylactic urticaria reproduced with kind permission of Dr Pete Smith, Medicalpix.com
• #7: NOTES FOR PRESENTERS: The NICE guideline contains 19 recommendations about how care can be improved. For this presentation we have divided the recommendations into six areas. The following slides will cover each of these areas in turn.
• #8: NOTES FOR PRESENTERS: This slide, along with the following two slides presents a list of signs and symptoms of possible food allergy. The lists are not exhaustive and the absence of these symptoms does not exclude food allergy. Key points to raise: Consider the possibility of food allergy when one or more signs or symptoms are present Pay particular attention to persistent symptoms that involve different organ systems. Recommendation 1.1.1 in full: Consider the possibility of food allergy in children and young people who have one or more of the signs and symptoms in table 1, below. Pay particular attention to persistent symptoms that involve different organ systems.
• #9: NOTES FOR PRESENTERS: This slide, along with the following previous and next slides presents a list of signs and symptoms of possible food allergy. The lists are not exhaustive and the absence of these symptoms does not exclude food allergy. Key points to raise: Consider the possibility of food allergy when one or more signs or symptoms are present Pay particular attention to persistent symptoms that involve different organ systems. Recommendation 1.1.1 in full: Consider the possibility of food allergy in children and young people who have one or more of the signs and symptoms in table 1, below. Pay particular attention to persistent symptoms that involve different organ systems.
• #10: NOTES FOR PRESENTERS: This slide, along with the following previous two slides presents a list of signs and symptoms of possible food allergy. In addition the assessor should also take note of any other signs and symptoms of systemic allergic reaction or anaphylaxis. Key points to raise: Consider the possibility of food allergy when one or more signs or symptoms are present Pay particular attention to persistent symptoms that involve different organ systems. Recommendation 1.1.1 in full: Consider the possibility of food allergy in children and young people who have one or more of the signs and symptoms in table 1, below. Pay particular attention to persistent symptoms that involve different organ systems.
• #11: NOTES FOR PRESENTERS: Key points to raise: For information about treatment for atopic eczema see ‘Atopic eczema in children’ (NICE clinical guideline 57) The clinical history should be taken by a healthcare professional with the appropriate competencies (either a GP or other healthcare professional). Physical examination should pay particular attention to growth and physical signs of malnutrition and signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic rhinitis). Recommendations in full Consider the possibility of food allergy in children and young people whose symptoms do not respond adequately to treatment for: • atopic eczema • gastro-oesophageal reflux disease • chronic gastrointestinal symptoms including chronic constipation [1.1.2] If food allergy is suspected (by a healthcare professional or the parent, carer, child or young person), a healthcare professional with the appropriate competencies (either a GP or other healthcare professional) should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. (recommendation truncated for slide set, for full list of factors to include, please consult quick reference guide) [1.1.3] Based on the findings of the allergy-focused clinical history, physically examine the child or young person, paying particular attention to: • growth and physical signs of malnutrition • signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic rhinitis). [1.1.4]
• #12: NOTES FOR PRESENTERS: Key points to raise: Blood tests should be offered for specific IgE antibodies to the suspected foods and likely co-allergens The choice between a skin prick test and a specific IgE antibody blood test should be based on the results of the allergy-focused clinical history and whether the test is suitable for, safe for and acceptable to the child or young person (or their parent or carer) and the available competencies of the healthcare professional to undertake the test and interpret the results.    Recommendations in full: Based on the results of the allergy-focused clinical history, if IgE-mediated allergy is suspected, offer the child or young person a skin prick test and/or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens. [1.1.5] Tests should only be undertaken by healthcare professionals with the appropriate competencies to select, perform and interpret them. [1.1.6] Skin prick tests should only be undertaken where there are facilities to deal with an anaphylactic reaction. [1.1.7] Image: Image showing skin prick testing reproduced with kind permission of Dr Pete Smith, Medicalpix.com
• #13: NOTES FOR PRESENTERS: Key points to raise: Blood tests should be offered for specific IgE antibodies to the suspected foods and likely co-allergens The choice between a skin prick test and a specific IgE antibody blood test should be based on the results of the allergy-focused clinical history and whether the test is suitable for, safe for and acceptable to the child or young person (or their parent or carer) and the available competencies of the healthcare professional to undertake the test and interpret the results.    Recommendations in full: Choose between a skin prick test and a specific IgE antibody blood test based on: • the results of the allergy-focused clinical history and • whether the test is suitable for, safe for and acceptable to the child or young person (or their parent or carer) and • the available competencies of the healthcare professional to undertake the test and interpret the results. [1.1.8] Do not carry out allergy testing without first taking an allergy-focused clinical history. Interpret the results of tests in the context of information from the allergy-focused clinical history. [1.1.9] Do not use atopy patch testing or oral food challenges to diagnose IgE-mediated allergy in primary care or community settings. [1.1.10]
• #14: NOTES FOR PRESENTERS: Key points to raise: Trial elimination should normally be for between 2-6 weeks Advice should be sought on nutritional adequacies, timings of elimination and reintroduction and follow up. Recommendation 1.1.11 in full: Based on the results of the allergy-focused clinical history, if non-IgE-mediated food allergy is suspected, trial elimination of the suspected allergen (normally for between 2–6 weeks) and reintroduce after the trial. Seek advice from a dietitian with appropriate competencies, about nutritional adequacies, timings of elimination and reintroduction and follow-up.
• #15: NOTES FOR PRESENTERS: Recommendations in full Based on the allergy-focused clinical history, offer the child or young person and their parent or carer, information that is age-appropriate about the: • type of allergy suspected • risk of severe allergic reaction • potential impact of the suspected allergy on other healthcare issues, including vaccination • diagnostic process, which may include: − an elimination diet followed by a possible planned rechallenge or initial food reintroduction procedure − skin prick tests and specific IgE antibody testing, including the safety and limitations of these tests − referral to secondary or specialist care. [1.1.12 ] Offer the child or young person and their parent or carer, information that is relevant to the type of allergy (IgE-mediated, non-IgE-mediated or mixed). [1.1.13] If a food elimination diet is advised as part of the diagnostic process (see recommendation 1.1.11), offer the child or young person and their parent or carer, taking into account socioeconomic status and cultural and religious issues, 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 procedure may be undertaken • the safety and limitations of the oral food challenge or food reintroduction procedure. [1.1.14]  
• #16: NOTES FOR PRESENTERS: Good communication between healthcare professionals and children or young people with a suspected food allergy is essential. It should be supported by evidence-based written information tailored to the needs of the child or young person and their family. Treatment and care, and the information children and young people are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Parents and carers should have the opportunity to be involved in decisions about treatment and care. Where appropriate, for example for older children, this should be with the child’s agreement. Parents and carers should also be given the information and support they need. Care of young people in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in ‘Transition: getting it right for young people’ (available from www.dh.gov.uk). Recommendations in full For babies and young children with suspected allergy to cows’ milk protein, offer: • food avoidance advice to breastfeeding mothers • information on the most appropriate hypoallergenic formula or milk substitute to mothers of formula-fed babies. Seek advice from a dietitian with appropriate competencies. [1.1.15] Offer the child or young person, or their parent or carer, information about the support available and details of how to contact support groups. [1.1.16 ] Image: Image showing severe urticaria reproduced with kind permission of Dr Pete Smith, Medicalpix.com
• #17: NOTES FOR PRESENTERS: Key points to raise: The algorithm on the following slides details indications for referral to secondary or specialist care. Recommendation 1.1.17 in full Based on the allergy-focused clinical history, consider referral to secondary or specialist care in any of the following circumstances. • The child or young person has: − faltering growth in combination with one or more of the gastrointestinal symptoms described in recommendation 1.1.1 − not responded to a single-allergen elimination diet − had one or more acute systemic reactions − had one or more severe delayed reactions − confirmed IgE-mediated food allergy and concurrent asthma − significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer. • There is: − persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms) despite a lack of supporting history − strong clinical suspicion of IgE-mediated food allergy but allergy test results are negative − clinical suspicion of multiple food allergies.
• #22: NOTES FOR PRESENTERS: Key points to raise: No evidence on the utilities of vega testing, applied kinesiology, hair analysis or serum-specific IgG testing in primary care was identified during the development of this guideline. Good quality evidence for alternative tests for food allergy is lacking, and the tests should not be undertaken. Recommendations in full Do not use the following alternative diagnostic tests in the diagnosis of food allergy: • vega test • applied kinesiology • hair analysis. [1.1.18] Do not use serum-specific IgG testing in the diagnosis of food allergy. [1.1.19]
• #23: NOTES FOR PRESENTERS: Because of the variation in current practice, it is not possible to quantify the national cost impact of the recommendations. Therefore, potential costs and savings need to be considered at a local level. Please refer to the costing report for further details. A summary of the costing report is given below: Costs The guideline recommends that healthcare professionals involved in the diagnosis of food allergy in children and young people should have the relevant skills and competencies. Feedback suggests that currently there is a lack of allergy specialists and the majority of GPs have not received sufficient training. It is likely that investment in training may be needed at a national level in order to fund additional training posts in allergy; however it is not anticipated that GP training will have a significant impact on NHS resources as training may be covered as part of continued professional development. Benefits and savings Implementing the clinical guideline may result in the following benefits: Improved training will lead to savings to the NHS from reduced GP appointments, avoidance of unnecessary testing and medication, and a reduction in emergency admissions. A potential shift from secondary care to primary care or specialist community-based allergy services may release hospital resources and reduce costs.
• #24: NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. Alternative questions: What are the local cost implications of implementing the guidance? What should we stop doing as a result of this guidance? Are there any particular food allergy examples that have occurred within the local patient group that can be used for discussion? (for example: what was the issue, how was it dealt with, were any changes made as a result?)
• #25: NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. A quick reference guide – a summary of the recommendations for healthcare professionals. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote reference numbers N2442 (quick reference guide) and/or N2443 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing report – gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Audit support – for monitoring local practice. Glossary of terms - extracted from the full guideline this may be useful for those who are not familiar with the medical terms used in the guideline. For example, it could be used to support a training session or discussion of the guideline.
• #26: NOTES FOR PRESENTERS: This slide is not part of the slide show, and is intended for use by the presenter only.