Memorandum by the Royal College of Paediatrics
and Child Health (RCPCH)
1. DEFINING THE
PROBLEM
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.
PREVALENCE (%) OF COMORBIDITY FOR ASTHMA,
ECZEMA AND ALLERGIC RHINITIS
| Number of diagnosed atopic conditions
| Age (years) 13-14
2-15
|
| 16-44 | |
| |
| 1 | 33 | 28
| 25 |
| 2 | 15 | 9 |
8 |
| 3 | 4 | 2 |
2 |
| At least one | 52 | 39
| 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. TREATMENT AND
MANAGEMENT
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. GOVERNMENT POLICIES
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. PATIENT AND
CONSUMER ISSUES
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.
REFERENCE LIST
[NOT PRINTED]
10 October 2006
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