Joint memorandum by Dr D E Lacy, Dr J
Seager and Mr A Bardsley (AL 69)
We enclose a memorandum from this Children's
Unit in a District General Hospital. This follows the structure
set out in the terms of reference. It includes an audit of the
activity in this Unit over the last year together with our recommendations
for Paediatric Allergy Services.
If you or the Committee would like us to attend
to answer questions or clarify any points we should be happy to
do so.
INTRODUCTION
This report is submitted to the Health Committee
by Dr D E Lacy and Dr J Seager, Consultant Paediatricians and
Mr A Bardsley, Directorate Manager on behalf of Wirral Services
for Child Health (WiSCH), part of Wirral Hospitals NHS Trust which
provides a National Health Allergy Clinic for children at Arrowe
Park Hospital. Wirral is part of the Cheshire and Merseyside Strategic
Health Authority. WiSCH provides integrated acute hospital and
community paediatric services for three Primary Care Trusts, (PCT),
Birkenhead and Wallasey, Bebington and West Wirral and Neston
and Ellesmere Port, serving a population of 360,000 people (80,000
children under 19 years of age). As there is no paediatric allergy
service nearer than Liverpool or Warrington the catcLiment area
extends beyond the PCT boundaries in the direction of the adjacent
city of Chester.
CLINICAL SERVICE
The Allergy Assessment Clinic is staffed (ref
1) by a Consultant Paediatrician, a Senior Paediatric Dietitian
and an Allergy Nurse Specialist who is also the Paediatric Asthma
Nurse Specialist for the Trust. At every third clinic a visiting
Consultant Allergist is present. The clinic is held in a dedicated
Paediatric Out-Patients Suite staffed by Children's nurses with
appropriate waiting area and trained appointment staff Acute paediatric
wards, Accident and Emergency services and a Children's Day Ward
are on the same site. School Nurses are managed by WiSCH so it
is possible to ensure that where parents and children want this
information and advice can be passed to teachers in all local
schools. A written protocol is supplied (ref 2) and where necessary
the Allergy Nurse can demonstrate the use of a pre-loaded epinephrine
(adrenaline) syringe. Two members of the paediatric nursing staff
are trained in the performance of skin-prick allergy tests and
these can be done during the clinic or on the Paediatric Day Ward
where food challenges are arranged by the Paediatric Dietitian
and carried out by a nurse supported by the paediatric medical
team where necessary. Food challenge protocols and emergency drug
regimens (ref 2) are subject to regular review by the hospital
Clinical Governance team and to appraisal by the Paediatric Pharmacist.
PATIENT ACCESS
Access to the clinic is by direct referral by
General Practitioners, by referral from consultant hospital or
community paediatricians or from other consultants eg in dermatology
or ENT. The proportion from each of these sources is detailed
in the evidence below. Waiting time in the last year has been
within Government requirements. All letters from OPs are reviewed
by a consultant paediatrician and children are assessed as requiring
an urgent, soon or routine appointment. Where appropriate children
are referred for dietitian's advice +/- skin-prick testing prior
to their clinic appointment.
PARENTAL CHOICE
Parents can exercise choice by asking their
general practitioner or consultant for referral to one of the
more distant clinics at Liverpool or Manchester (where there is
a professor of paediatrics with an interest in allergy), but perhaps
because we are able to offer a reasonably rapid service which
includes dietitian, specialist nurse and school liaison, we find
that the referral trend seems to be slowly in the other direction.
Not all local general practitioners are aware of the service we
offer, but this situation is improving.
Local alternative medical practitioners offer
various services (see the Vega testing leaflet ref 3). We do not
know how widely these alternative services are used. Some parents
come to us after they have had a battery of investigations done
at their own expense and are concerned to know the implication
for their child when, for example, a test is positive for wheat.
This includes children who have had radioallergosorbent (RAST)
tests done by privately run biochemistry laboratories where standards
and quality control may be high, but no advice is given on the
significance of the finding or the consequences of an exclusion
diet for a growing child.
The evidence below has been gathered by examining
records of the most recent 100 new patients seen at the Allergy
Clinic up to April 2004.
AUDIT OF SERVICES PROVIDED AT ALLERGY ASSESSMENT
CLINIC AT ARROWE PARK HOSPITAL
|
| Age range (at next birthday): | 1-15 years
| |
| Referral by: | General Practitioner
| 71% |
| Paediatrician | 23% (this will include children who have presented to the emergency services in the hospital with acute anaphylaxis) 7% were referred by community paediatricians
|
| Other consultants: | 4%
|
| Not recorded | 2%
|
|
SUSPECTED ALLERGY TO: (NUMBER OF CHILDREN REPORTED)
Foods:
|
| Peanut | 53 |
| Egg | 25 |
| Mild | 15 |
| Hazelnut | 7 |
| Cereals | 6 |
| Cashew | 5 |
| Almond, brazil, strawberry | 4
|
| Peas, prawns, sesame | 3 |
| Apple, baked beans, blackcurrant, chocolate, fish, papaya, potato
| 2 |
| Amaretto, aniseed, apricot, avocado, broccoli, cheese, cherry, grapefruit, ice cream, Jelly Tots, lentil, melon, nectarine, peach, pecan, plumb, rhubarb, raspberry, soya, tangerine, Thai fish sauce, tuna
| 1 |
Non-foods:
Cat |
17
|
| Dog | 14 |
| Soaps, detergent | 3 |
| Hamster | 2 |
| Latex | 2 |
| Amoxil, Calpol, chlorine, diesel, Elastoplast, gnat bite, guinea pig, lanolin, Micropore, morphine, pine trees, Piriton, wax crayons
| 1 |
| Reported 5 or more non-food allergens: |
3% |
| Insect Sting: | 2% |
| Maternal Pica: | 26% |
Complicated Birth: (pre-term, LUSCS, forceps/Ventouse,
intubated at birth)
| 5% |
| Breast Fed: | 54% |
| (breast-fed for more than one month 45%)
|
| Previous eczema: | 80% |
| Previous asthma: | 52% |
| Previous hayfever: | 32% |
| First degree relative with: |
|
| Eczema: | 32% |
| Asthma: | 38% |
| Hayfever: | 50% |
| Allergy: | 38% |
| History of relatives with food allergy as sole reason for referral to the clinic:
| 5% |
|
Epinephrine Prescription
Epinephrine pen prescribed at clinic or GP asked to prescribe:
26% (peanut 23, brazil 2, cashew 1)
Epinephrine pen already prescribed: 9% (peanut 6, wasp, cashew,
pollen)
Parents advised and considering its use: 10% (peanut 8, almond,
latex)
The epinephrine pen was prescribed or advised for 28 of the
34 children, ie 82% who had both peanut allergy and asthma. It
was prescribed for 8 of the 18 children, ie 44% who had peanut
allergy, but did not have asthma.
Skin-prick Tests
These were performed on 26% of the children. Approximately
75% were positive, 25% negative.
Food challenges
Total tests done 1.5.03 to 1.5.04. 62 (egg 27, peanut 13,
milk 9, cod and hydrolysed feeding formula 3, almond, salmon,
brazil nut 2, anchovy 1). Each challenge test takes approximately
five hours from start to finish.
Associated Issues
(a) High incidence of atopic disease including eczema.
asthma and allergic rhinitis which is present in children referred
with food allergy. Advice on eczema can easily be given in the
setting of a paediatric clinic. A key requirement in the management
of severe food allergy in children is to ensure good asthma control
because in addition to anaphylaxis food allergy can trigger a
life-threatening attack of asthma. This is much less likely to
happen if regular appropriate asthma treatment is being taken.
The Asthma/Allergy Nurse Specialist is able to pick up on these
issues and address them at clinic or afterwards.
(b) Severe allergy might be defined as a history of life-threatening
episodes in the past or by reported allergy to multiple different
substances. In either case the problems are best addressed by
the same team as is involved with the more routine cases as most
of the issues are identical and support will need to be co-ordinated
locally at home and at school. Emergency treatment will also need
to be close at hand.
(c) Although enquiries about immunisation from general
practitioners are generally directed to a consultant community
paediatrician parents often raise queries about particular immunisations
at the Allergy Clinic. This is a useful opportunity to answer
questions and to discuss anxieties about some widely held misunderstandings
such as the belief that MMR immunisation caunot be given to children
who have egg allergy. When concerns persist the offer to do the
immunisation on the Paediatric Day Ward will sometimes ensure
that a child gets immunised.
(d) Finally, problems such as cow's milk allergy or intolerance
are common in infancy and are generally dealt with outside the
Allergy Clinic, either by the Primary Health Care Team or in general
paediatric out-patients clinics. This seems entirely appropriate.
However, severe or persistent problems would benefit from assessment
in the Allergy Clinic. Milk and egg challenges can then, if necessary,
be arranged on the Children's Day Ward.
(e) Desensitisation treatment would be referred to a
Regional Allergy Clinic.
RECOMMENDATIONS
1. PCTs should be resourced to provide a paediatric allergy
service with ready access to a clinic serving a population group
of approximately 500,000 people. Central to this is the need for
funding for an appropriate number of service sessions by the paediatric
dietitian.
2. Allergy in children should be managed as an integral
part of children's health services as it affects infant and child
nutrition and growth and has important psychological and educational
consequences.
3. Paediatric Allergy Clinics should offer the services
of a paediatric dietitian, a paediatric allergy nurse, preferably
with training in the management of paediatric asthma and a consultant
paediatrician. Combined clinics with a consultant allergist on
an intermittent basis are of great benefit if the clinic is held
in a District General Hospital. As there is nationally a shortage
of consultant allergists a service such as ours would benefit
from increased numbers in that speciality.
4. Paediatric Allergy Clinics should have the facilities
to carry out skin-prick and RAST tests and have ready access to
Paediatric Day Ward facilities for performance of food challenges.
Day Wards should have the immediate availability of medical staff
trained in Paediatric Life Support. Challenges should be carried
out according to regularly reviewed protocols.
REFERENCES
Ref 1: Full details of sessional time worked by Consultant
Paediatrician, Senior Paediatric Dietitian and Allergy Nurse available
from Directorate Management Team, WiSCH—tel: 0151-482 7868;
fax: 0151-482 7875
Ref 2: Copies of all protocols issued at the Allergy
Clinic and protocols used for food challenges and emergency drug
treatment available as above on request.
Ref 3: A copy of alternative medicine (Vega testing)
advertised locally and featuring a picture of a child undergoing
assessment available on request.
May 2004
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