BSACI 2021 guideline for the management of egg allergy

This guideline advises on the management of patients with egg allergy. Most commonly egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history will confirm the diagnosis in most cases. Investigation by measuring egg-specific IgE (by skin prick testing or specific IgE assay) is useful in moderate-severe cases or where there is diagnostic uncertainty. Following an acute allergic reaction, egg avoidance advice should be provided. Egg allergy usually resolves, and reintroduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive the MMR vaccine. Most adults and children with egg allergy can receive the influenza vaccine in primary care, unless they have had anaphylaxis to egg requiring intensive care support. Yellow Fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence based. Where evidence was lacking, consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.

BSACI guideline for the diagnosis and management of peanut and tree nut allergy

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required.

A meta-analysis of montelukast for recurrent wheeze in preschool children

There is conflicting evidence of the effectiveness of montelukast in preschool wheeze. A recent Cochrane review focused on its use in viral-induced wheeze; however, such subgroups are unlikely to exist in real life and change with time, recently highlighted in an international consensus report. We have therefore sought to investigate the effectiveness of montelukast in all children with preschool wheeze (viral-induced and multiple-trigger wheeze). The PubMed, Cochrane Library, Ovid Medline and Ovid EMBASE were screened for randomised controlled trials (RCTs), examining the efficacy of montelukast compared with placebo in children with the recurrent preschool wheeze. The primary endpoint examined was frequency of wheezing episodes. Five trials containing 3960 patients with a preschool wheezing disorder were analysed. Meta-analyses of studies of intermittent montelukast showed no benefit in preventing episodes of wheeze (mean difference (MD) 0.07, 95% confidence interval (CI) -0.14 to 0.29; mean for montelukast 2.68 vs placebo 2.54 (p = 0.5)), reducing unscheduled medical attendances (MD -0.13, 95% CI -0.33 to 0.07; mean for montelukast 1.62 vs placebo 1.78 (p = 0.21)) and reducing oral corticosteroids (MD -0.06, 95% CI -0.16 to 0.02; mean for montelukast 0.35 vs placebo 0.36 (p = 0.25)). The pooled results of the continuous regimen showed no significant difference in the number of wheezing episodes between the montelukast and placebo groups (MD -0.40, 95% CI -1.00 to 0.19; mean for montelukast 2.05 vs placebo 2.37 (p = 0.18)).

CONCLUSIONS

This review highlights that the currently available evidence does not support the use of montelukast in preschool children with recurrent wheeze. We recommend further studies to investigate if a 'montelukast responder' phenotype exists, and how these can be easily identified in the clinical setting. What is Known: • Current guidelines recommend montelukast use in preschool children with recurrent wheeze. • A recent Cochrane review has found montelukast to be ineffective at reducing courses of oral corticosteroids for viral-induced wheeze. What is New: • This meta-analysis has examined all children with preschool wheeze and found that montelukast was not effective at preventing wheezing episodes or reducing unscheduled medical attendances. • A specific montelukast responder phenotype may exist, but such patients should be sought in larger multicentre RCTs.

At greatest risk: pre- and early adolescent Bahamian youth experiencing anal intercourse

Although anal intercourse carries great risk for HIV transmission, little research has focused on it among the general population, particularly pre- and early adolescents. This study describes the prevalence of anal and vaginal intercourse among Bahamian pre- and early adolescents and associations with other risk behaviours, family interactions and intrapersonal correlates. Data were from 1274 sixth-grade students aged 9–14 years who completed self-administered questionnaires at baseline of a larger school-based behavioural intervention study. Youth who reported having had anal intercourse engaged in significantly higher rates of several risk behaviours and were significantly more likely to engage in risk behaviours over the next six months, compared with youth with a history of vaginal intercourse only, who in turn were more likely than virgin adolescents. Youth indulging in anal intercourse also perceived significantly lower levels of parental monitoring. Multivariate analyses revealed that anal intercourse, vaginal intercourse, reduced parental monitoring, depression and perceived friend high-risk involvement were associated with both past involvement and future intention to engage in other risk behaviours. Anal intercourse poses a direct threat to the health of these children and is a flag for a constellation of other risks.

The RCPCH care pathway for children with drug allergies: an evidence and consensus based national approach

AIMS

The Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the Department of Health to develop a drug allergy pathway. It focuses on defining the competences to improve the equity of care received by children.

METHOD

The drug pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The team decided to focus on IgE-mediated reactions as these have the greatest potential to be life-threatening.

RESULTS

The results are presented in four parts: evidence review, pathway mapping, external review and core knowledge documents. The evidence review found a high percentage of putative penicillin allergy is not confirmed by objective testing and that resensitisation to β-lactam drugs was infrequent. It also highlighted the importance of a detailed history and accurate diagnosis along with clear communication of test results to both family and primary care.

CONCLUSIONS

This pathway demonstrates the spectrum of drug allergy is varied and may differ for young children compared with older children and adults. The authors highlight the paucity of evidence to support allergy testing for most drugs, in children, other than supervised incremental provocation tests (when indicated). Acute presentations require emergency health professionals to address underlying allergic issues, including recognition and avoidance of potential drug allergy triggers. Non-acute presentations may include multi-system symptoms which may have a broad differential diagnosis; this document signposts to the relevant partners in the RCPCH care pathway portfolio. Management combines a care package including a definitive diagnosis, initiating treatments and ongoing education.

The RCPCH care pathway for children with venom allergies: an evidence and consensus based national approach

AIMS

The Royal College of Paediatrics and Child Health (RCPCH) Science & Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the venom allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions.

METHOD

The RCPCH venom allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee.

RESULTS

The pathway results are presented in four parts: evidence review, mapping, external review and core knowledge documents. The entry points are defined and the ideal pathway of care is described from self-care through to follow-up. The evidence highlighted that venom immunotherapy is safe and effective for bee and wasp allergy and that there are real quality of life benefits for patients. The review also highlighted the value of measuring serum tryptase after reactions.

CONCLUSIONS

The venom allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible. The authors recommend that this pathway should be implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.

The RCPCH care pathway for children with latex allergies: an evidence- and consensus-based national approach

AIMS

The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the latex allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions.

METHOD

The RCPCH latex allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee.

RESULTS

The results are presented in four parts, the evidence review, pathway mapping, external review and core knowledge documents. The evidence review highlighted the paucity of recent evidence for latex allergy in childhood. The review found that the diagnostic sensitivity of different latex extracts for skin-prick testing may differ. It also noted that health professionals should be aware of latex allergy, and care should be taken to avoid contact with latex in young infants, especially when there is a family history for latex allergy. The pathway entry points are defined by the severity at presentation.

CONCLUSIONS

The latex allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patients home as possible. The authors recommend that this pathway is implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.

The socio-economic determinants of obesity in adults in the Bahamas

OBJECTIVE

To determine the socio-economic determinants of obesity in adults in The Bahamas.

DESIGN AND METHODS

A subpopulation of adults 21 to 60 years was analysed for socio-economic differences in obesity levels. Data from the 2001 Bahamas Living Conditions Survey, a nationwide comprehensive household survey which included anthropometric measurements, were used. Bivariate and binary logistic regression methods for complex samples were employed.

FINDINGS

Overall obesity prevalence was 32% (38% female, 25% male, p = < 0.0001). An inverse relationship by education appeared to be the strongest predictor for all persons (OR = 0.78, CI 0.67, 0.90; p < 0.0001). This relationship was also evident for females (OR = 0.71, CI 0.59, 0.85; p < 0.0001) while a positive relationship existed by economic level for males (OR = 1.23, CI 1.07, 1.41; p = 0.005). There was a difference in food group expenditure for starchy vegetables only (p = 0.049). Other food group household expenditure, urban residence and female headed households showed no significant differences by obesity.

CONCLUSIONS

In line with international trends, obesity rates are high in The Bahamas, and especially affect females of lower socio-economic status. Public policy that targets this group is necessary to address this health concern.

Effects on condom use of an HIV prevention programme 36 months postintervention: a cluster randomized controlled trial among Bahamian youth

Data are lacking on long-term effects of HIV behavioural intervention programmes. In this study, we report intervention effects 36 months postintervention on condom use and relevant outcome variables from the theory-based programme 'Focus on Youth in the Caribbean' (FOYC). Participants (1360 sixth-grade youth) were randomized by school into: (1) FOYC, plus one of two brief parent interventions or (2) the control condition 'Wondrous Wetlands', plus a brief parent intervention. Mixed effect analysis demonstrated significant programme effects, including enhanced HIV/AIDS knowledge (effect size D = 0.44, 95% confidence interval [CI]: 0.43, 0.46), increased self-efficacy of (D = 0.42, 95% CI: 0.30, 0.54), skills for (D = 0.62, 95% CI: 0.56, 0.64) and intention to use a condom (D = 0.20, 95% CI: 0.03, 0.37). Youth who received FOYC plus the parental monitoring intervention had higher condom use rates (odds ratio = 1.49, 95% CI: 0.97, 2.28). Feedback effects from key variables were also detected, supporting the sustained effect.

British Society for Allergy and Clinical Immunology guidelines for the management of egg allergy

This guideline advises on the management of patients with egg allergy. Most commonly, egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history and the detection of egg white-specific IgE (by skin prick test or serum assay) will confirm the diagnosis in most cases. Egg avoidance advice is the cornerstone of management. Egg allergy often resolves and re-introduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive measles, mumps and rubella (MMR) vaccination. Influenza and yellow fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence-based but where evidence was lacking consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.

Condom-use skills checklist: a proxy for assessing condom-use knowledge and skills when direct observation is not possible

Because of the continued importance of correct condom-use in controlling the HIV epidemic and the limited availability of tools for assessing correct condom-use, methods for assessing condom-application skills, especially when direct observation is not feasible, are needed. Accordingly, in the context of a high-risk population (The Bahamas) for HIV, a 17-item scale--the Condom-use Skills Checklist (CUSC)--was developed for use among young adolescents and adults. The rationale and approach to developing the scale and some measures of internal consistency, construct validity, and criterion-related validity have been described. It is concluded that the scale offers a reasonable alternative to direct observation among older subjects and that further development may make it more useful among pre-adolescents.

Epidemiological profile of cancer for Grand Bahama residents: 1988-2002

This retrospective and observational study is based on a review of data from the pathology ledgers and clinical records of the Rand Memorial Hospital, of diagnoses and deaths from cancer from 1988 to 2002 (15 years). The aim was to determine the cancer incidence, mortality, survival rates and the trends for the island of Grand Bahama, Bahamas. The records indicated at least 545 (males: 187; females: 358) new cancer diagnoses giving an approximate age-standardized annual incidence rate of 167.7 per 100,000. The most frequent cancers were, in males (except for skin keratinocytic cancers) prostate 21.9%, colon/rectum 12.8% and lung 6.4%; and in females: breast 45.3%, cervix uteri 16.8% and colon/rectum 6.4%. Of these cancers, 443 (81.3%) were diagnosed in the pathology department of the hospital with the median age at diagnosis of all persons being 52 years. This comprised 119 males and 324 females. Whereas the majority of breast and cervical cancers were histologically diagnosed locally, those of prostate and lung were not. During the period, 359 (males: 181; females: 178) persons had died from cancer; an annual age-standardized mortality rate of 114.8 per 100,000, with breast 19.2%, prostate 14.5% and colon/rectum 9.5% being the most frequent. The overall median period of survival was one year (range 0-14 years). The median survival for persons with cervix uteri was five years; for breast cancer, three years; colorectal cancer, 2 years; prostate, one year; and less than a year for lung cancer. The data on cancer were not easily obtained and this may be improved if a cancer registry is established on this second most populated island of The Bahamas.

Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial

BACKGROUND

A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of acute asthma. In developing countries, commercially produced spacers are generally unavailable or too costly. We tested the efficacy of home-made spacers (500 mL plastic bottle, polystyrene cup) compared with a conventional spacer for delivery of a beta2 agonist via MDI for children with acute asthma.

METHODS

We studied children aged 5 to 13 years with acute asthma, stratified into those with mild airways obstruction (peak expiratory flow [PEF] 60-79% of predicted value) or moderate to severe airways obstruction (PEF 20-59% of predicted value). A beta2 agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, sealed 500 mL plastic bottle, unsealed 500 mL bottle, 200 mL polystyrene cup). Clinical score, pulmonary function tests, and oximetry were recorded at baseline and 15 min after treatment. If a second bronchodilator treatment was needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonary function, and need for and response to nebulisation.

FINDINGS

88 children were eligible for study. In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilation (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebulisation was required by ten of 11 who had used a cup, nine of 11 who had used an unsealed bottle, eight of 11 who had used a sealed bottle, and only four of 11 who had used a conventional spacer. After nebulisation, improvement in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), sealed bottle (3%; 0%), or unsealed bottle (7%; 9%). For 44 children with mild airways obstruction, response to bronchodilator was similar for all spacers and need for nebulisation was not associated with use of a particular spacer.

INTERPRETATION

A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.