Select Committee on Science and Technology Minutes of Evidence

Memorandum by the Royal College of Paediatrics and Child Health (RCPCH)


1.1  Allergy and Intolerance

  Hypersensitivity or intolerance is an umbrella term that refers to reproducible symptoms or signs to a defined stimulus at a dose tolerated by normal subjects. It includes non-allergic hypersensitivity, such as lactose intolerance and reactions to caffeine, and allergic diseases such as eczema, asthma, food allergies, rhinitis, drug allergy, venom and latex allergy. In addition many people have a misconceived belief their child is allergic. Such individuals also required accurate assessment in an allergy clinic.

1.2  Origins of allergic disease

  A good deal is known about the immunological basis of allergy, but underlying causes of allergic conditions are more difficult to understand. Changes in prevalence over the last four to five decades cannot be readily explained, although a number of theories have been proposed and most have focussed on early-life interactions between genes and environment such as allergen exposure in pregnancy and infancy, maternal and infant feeding practices, viral and bacterial infections in infancy, environmental tobacco smoke, pollutants, pet contact, family size and rural living. Family history is clearly an important risk factor for allergy. Twin studies have suggested that as much as 75 per cent of the risk of developing allergic rhinitis may be genetic. Family studies have identified a number of genes that predispose to developing both asthma and atopy. As in other complex conditions, genes interact significantly with each other and with environmental factors to affect the risk of developing disease. Exposure to infections or allergens before and immediately after birth may be significant. Allergy is also less likely to develop in children with older siblings and in children brought up on farms or in close contact with animals. Breast feeding reduces the risk of infant wheezing and food allergy in infancy but may not reduce the chance of developing asthma or other significant allergies in later life. Maternal smoking during pregnancy and in the first few years of life increases the risk of asthma. Obesity also makes asthma more likely. The relative roles of allergen exposure and avoidance in the development of allergy are unclear and conflicting. For example, exposure to cats in infancy may induce tolerance and prevent the development of asthma and wheeze. Conversely, exposure to animals in a sensitised child may exacerbate wheezing symptoms. Similarly, prolonged breastfeeding and the use of hypoallergenic milk formulas has a transient impact on preventing the development of eczema and food allergy in infancy. It is currently unclear as to whether avoiding allergens or early exposure is the best recommendation for preventing the development of allergy.

1.3  The progression of allergic disease

  The progression of allergic disease is well documented. Indeed the progression from food allergy and eczema in infancy to rhinitis and asthma in mid-childhood is often described as the allergic march. Most food-induced symptoms presenting in infancy have resolved by three years of age. Cows milk allergy affects about 5 per cent of children with a remission rate of 50 per cent per year for the first three years of life. Egg allergy affects 2.6 per cent of children with 50 per cent remission at four to five years of age. Peanut allergy affects 1 per cent of children, preschool children have an 18 per cent chance of resolution. Seafood allergy affects 0.6 per cent of children with about 4 per cent giving a history of having outgrown their allergy. 50 per cent of children with eczema will have outgrown it by six years of age and two to three will have outgrown it by 14 years of age. Most asthma has its origins in childhood. More asthma persists through adolescence than is generally believed and even in those cases that remit many recur in adulthood. The prevalence of asthma in children aged 9-11 years is double that in adults from the same country and region, as is the prevalence of bronchial hyperresponsiveness. Wheezing illness is at its most frequent in the pre-school period with 50 per cent of children experiencing wheezing before the age of six years. The prevalence of wheezing illness drops from 50 per cent at age 7 to 18 per cent at age 11 and to 10 per cent at age 16. Clinical studies report up to 80 per cent of asthmatics lose their symptoms during puberty. After puberty asthma prevalence rises again—to 27 per cent by age 33. The pattern of disease in early life dictates the way in which it evolves through childhood. Thus paediatricians are in the ideal position to modify outcomes.

1.4  The rising incidence of allergy and high UK prevalence

  The reasons for the rising incidence of allergy and allergic disease are unclear, but have been associated with increasing affluence. Worldwide variation in rates of atopic disease suggest that environmental factors are critical to the development of these disorders in childhood. Within the United Kingdom, atopic disease is significantly higher in Scotland and Northern England.

1.5  Gaps in establishing the overall disease burden

  In Britain, there is little reliable information at the national level about the nature and magnitude of the burden posed by allergic conditions and the costs that these incur. The ISAAC study estimated the prevalence of asthma, hayfever and atopic dermatitis in six to seven year olds and 13 to 14 year olds as part of a worldwide study. These data are limited by the validity of patient recalls of an allergy diagnosis (less so in the ISAAC study). The UK prevalence of food allergy and other allergic diseases are less well documented with no good population-based studies of prevalence. Research studies looking at prevalence are often small and localised, making it difficult to obtain an overall picture of the disease burden in the United Kingdom. A central funding body for allergy research would help to address this. Within medical practice, allergy as a disease entity is coded as one of 17 definitions on ICD 10. Allergic disease is also often coded under the organ specific manifestation such as eczema or asthma. These are complex conditions, where disease definitions are unclear or ambiguous and there is a lack of uniform methods of data collection. Allergic conditions often occur together. Co-morbidity has been studied in a number of settings. Figures for prevalence vary, partly because problems of diagnostic variability and ascertainment are multiplied when more than one case definition is applied. At the same time the severity of the combined problems are underestimated Allergic rhinitis is present in at least 75 per cent of people with asthma and increases the cost of their care and the burden of disease impacts exponentially on the sufferers.

Number of diagnosed atopic conditions
Age (years) 13-14


13328 25
2159 8
342 2
At least one5239 35

1.6  The socio-economic impact of allergic disease

  An assessment of the burden of healthcare costs of respiratory allergic disease has been made at over one billion pounds per year. Asthma is a leading cause of hospital admission in children. Rhinitis significantly reduces quality of life, interferes with attendance and performance at school and results in substantial NHS costs. There are additional economic implications for parents also needing to take time off from work to look after their children. Results of examinations held during the summer are significantly lower in hayfever sufferers. Children with hayfever may drop a grade as a result of their symptoms. The relationship between reduced final school grade results and reduced income generated once these children reach employment has added economic implications. Shopping for a child with nut allergy takes 39 per cent longer and increases the cost of the weekly shopping basket by about 11 per cent.


2.1  Current treatments—effect on natural history

  The majority of treatments currently employed in the UK centre on symptom control. Effective treatment of allergic rhinitis improves symptoms of asthma and reduces emergency treatment and hospitalisation for asthma. Allergen avoidance is also important in controlling symptoms once they have developed. Cochrane reviews have demonstrated the efficacy of immunotherapy for the treatment of asthma and rhinitis Immunotherapy is the only treatment capable of modifying the natural history of the disease. For treatment of allergic rhinitis, it induces long term remission, prevents spread of sensitisation to other allergens and prevents the progression to asthma in children. Immunotherapy cures 95 per cent of patients with bee and wasp venom allergies. When a patient presents with allergic symptoms, accurate diagnosis and assessment of other allergic conditions reduces comorbidity. For example, detection of persistent sensitisation to egg and/or aeroallergens in infants with eczema highlights a group at risk of progression to asthma, who may benefit from early intervention.

2.2  Evidence base for pharmacological and non-pharmacological strategies

  There is a good evidence base for pharmacological strategies, particularly for the management of asthma and rhinitis using inhaled and nasal steroids, antihistamines, bronchodilators and leukotriene receptor antagonists. The evidence base for non-pharmacological strategies, including allergen avoidance, is less clear. A Cochrane review of House dust mite reduction measures reported an improvement in rhinitis symptoms. This effect is more pronounced in children than in adults. The relative lack of evidence for non-pharmacological strategies may be impacted by sources of funding for allergy research. Research into non-pharmacological strategies would be enhanced by a centralised source of allergy funding, independent of the pharmaceutical industry.

2.3  UK research into allergy and allergic disease

  The United Kingdom has a paradox of having excellent allergy researchers in several centres. Translating their research into clinical practice is restricted by a lack of centres for the practice of clinical allergy. As previously stated, there is no central funding body for allergy research. Investment in allergy research is therefore less than in other high cost areas. Allergy centres are therefore compelled to compete with higher profile translational research areas such as neurosciences, cardiovascular disease, obesity and ageing.

2.4  Research into the prevention and treatment of allergy

  Research into the prevention and treatment of allergy needs to focus on immune modulation and treatment in early life, to reduce the burden of disease and prevent the progression of the atopic march. Allergen avoidance as a principle of primary prevention has been shown to be ineffective and allergen exposure in infancy may be protective against the development of allergy. Further work needs to be done to establish this. Vaccines, prebiotics, probiotics and reduction of allergen exposure are all promising areas; as is the effect of nutrition and potential for disease modification. The demographics of obesity mimic that of allergy. There is potential for exploring the relationship of allergy with the increase in obesity; also obesity prevention and its effect on allergy.


3.1  Effect on addressing the rise in allergies

  Government policy and advice has been ineffective in preventing the rise in allergies. In 1999, the DOH recommended that pregnant mothers should avoid eating peanuts to reduce the incidence of peanut allergy. The United Kingdom was the only European country to make this recommendation. Surveys have suggested that the advice was not heeded by the target population, which indicates that the strategies employed by DOH to promote health are defective. In the event subsequent research has demonstrated that avoidance diets do not prevent antenatal allergen exposure and may, paradoxically, lead to an increase in the development of food allergy. Other allergen avoidance strategies for the primary prevention of food allergy (prolonged breastfeeding, use of hydrolysed formulas and avoidance of allergenic food) are relatively ineffective. A more secure evidence base is therefore needed before recommendations are made to the general public. Future recommendations will need to be clear and widely available. They will need active re-inforcement in order to be effective.

3.2  How current knowledge is shared with the Government

  Within the allergy community, knowledge about causes and management of allergic disease are shared through the British Society for Allergy and Clinical Immunology. Knowledge about allergic disease affecting children is shared through the British Paediatric Allergy, immunology and infectious diseases subgroup of the Royal College of Paediatrics and Child Health. Allergic disease is complex and management initiatives need to be considered within the full context of allergic disease. Both of these organisations should have a wider role in informing government policy. Information appears to be fed through to the government on a piecemeal basis. There is a lack of representation of the needs of allergy patients and allergy services at a government and Department of Health level.

3.3  Housing policy

  Housing policy currently focuses on energy saving. This conflicts with the needs of allergy patients because indoor allergen and pollutant levels increase as air exchanges decrease. Patients with allergies need improved ventilation systems in their houses. Indoor air humidity also needs to be taken into account. The United Kingdom has a very damp climate and high humidity levels inside houses, compounded by washing and cooking in homes with reduced ventilation lead to high levels of humidity, pollutants such as nitrogen oxides, volatile organic compounds etc, moulds and house dust mite in British homes. Both increased damp and house dust mite levels are significant risk factors for the persistence of symptoms in children with asthma. The type of building (houses vs. flats), ventilation system and presence of a basement all have major implications on respiratory symptoms, atopy and house dust mite infestation. Building construction affects both respiratory morbidity and allergic sensitisation through development of disease and worsening of symptoms.

3.4  Food policy and labelling regulations

  Policy for food labelling is now directed by the European Union and is consequently relatively responsive and allergy aware. The Food Standards Agency enforces food labelling regulations and operates with allergy consumer input from the Anaphylaxis Campaign. Recent changes to the recommendations for food labelling have improved the information available to consumers, but are not patient centred and, in some cases, has increased the confusion experienced by allergy sufferers. Alternative foods for allergy sufferers are expensive and may not be readily available. 56 per cent of food items indicate that they contain traces of nuts, there are no substitutes for 18 per cent of items and 9 per cent are of poorer quality. The recent campaign for healthy eating in schools has not taken into account the needs of peanut allergic children. Recommending that nuts should be increasingly available as a healthy snack from vending machines increases the risk of allergy sufferers having an acute reaction by inadvertent exposure.


4.1  Impact of allergy on quality of life

  Quality of life of children with peanut allergy is more impaired than in children with diabetes. Teenagers with allergic rhinoconjunctivitis experience impaired quality of life due to local and systemic symptoms, limited activity and emotional and practical problems. 7 per cent of children are affected by more than one allergic condition. The impact on quality of life of co-morbidity is difficult to study. For example, the effect of rhinitis and sleep disturbance on school performance and the impact on exam results and career attainment is not well documented. The timing of exams are important, children with summer hay fever will drop a grade when they sit their exams which are usually scheduled for the middle of the grass pollen season. Venom immunotherapy offers improved quality of life over provision of rescue medication alone in patients with severe reactions to wasp stings.

4.2  Better education of public and patients

  The fundamental problem is that a patient often suspects that they have an allergy, but, because of lack of access to accurate allergy diagnostic procedures, they are unable to obtain accurate and effective advice (similar to a patient, suspecting they might have cancer, the first step would be to be referred somewhere where an accurate diagnosis can be made, before effective treatment can be given). We have effective treatments, but there is a gap in access to accurate allergy diagnosis forcing patients to access alternative, inaccurate and inappropriate advice through complementary medicine. This is compounded by misconceptions in the popular press. A programme of health promotion and health education and an increased awareness of allergy is needed within the general population, patient population and primary care. For general practitioners, there is a lack of teaching in medical schools at undergraduate and postgraduate levels resulting in a significant knowledge gap and a need for GP education programmes supported by a network of specialists. Currently, there is an information vacuum allowing pharmaceutical companies to provide promotional material inappropriately (for example, recommending the use of sedating anti-histamines for the treatment of hay fever). It also leaves appliance companies relatively unregulated in relation to claims about health benefits such as for vacuum cleaners, air filters, ionisers etc. The public tends to get an unbalanced view of allergy and the options available for treating it. There is a need for a centrally funded allergy awareness strategy, which is not commercially linked. A schools education programme would improve allergy awareness for children.

4.3  Regulation of private clinics

  Legally constituted regulation is imposed on medical practitioners by the General Medical Council, whether they work in the private sector or for the National Health Service. Private medical clinics are increasingly incorporating governance standards used within NHS clinics and hospitals. Children with allergic disease are significantly more likely to seek advice from alternative medicine practitioners than children with other illnesses. This may reflect a lack of adequate service provision for these children or insufficient knowledge regarding the management of allergies in primary care. Non-medically qualified practitioners are able to freely practice subject to minor limitations. This unregulated situation has existed since the 16th century. There is considerable variation in the levels of professionalisation within the Complementary and Alternative Medicine world. Osteopathy and chiropractic are the only two complementary professions with statutory regulation. Other practitioners, such as herbalists, homeopaths, Chinese medicine practitioners and accupuncturists are regulated through voluntary professional organisations and are able to make unsubstantiated claims without challenge. Nutritionists without formal dietetic training who recommend dietary exclusion in infants based on unfounded tests are a particular problem. Unregulated peanut desensitisation has the potential for severe adverse effects. Kinesiology, vega testing and hair analysis as forms of allergy testing have no scientific rationale and are not valid diagnostic procedures.

4.4  Paediatric allergy training and service provision

  Allergic disease has its basis in childhood. As a consequence the management of allergic disease requires an understanding of the developmental aspects of the child including physiology, nutrition and immunity. It is therefore regrettable that there are very few paediatric allergy specialists in the UK; nine specialists overall of whom six are based in London. Furthermore there are no established training programmes for paediatricians wishing to become specialists in allergy. The College of Paediatrics Special Advisory Committee is attempting to correct this but currently only two centres in the UK can provide the training to obtain the competencies required by a paediatric allergist. More tertiary centre based paediatric allergists are required—not only to treat the most complex cases but to provide research into the paediatric aspects of allergic disease and to provide the necessary training for future generations of paediatric allergists. While much paediatric allergy is dealt with at primary and secondary care level, tertiary specialists can fulfil a key role in providing a network for guidance and support to these clinicians.


10 October 2006

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