The prevalence of allergy in the UK is one of the highest in the world at over 20 per cent of the population. Food allergies in particular are thought to be on the rise and pharmacy teams can be on hand to offer support and signposting
Hospital admissions due to food-induced anaphylaxis (serious allergic reactions) tripled between 1998 and 2018 in the UK, according to research published in the British Medical Journal (BMJ) in February 2021, but deaths due to food anaphylaxis halved during the same period.
The researchers from Imperial College London’s National Heart and Lung Institute found that while severe reactions to peanuts and tree nuts appear to be decreasing, severe reactions to cows’ milk are on the rise, especially in school-aged children, and that teenagers and young adults are at the highest risk of severe and fatal food-related allergic reactions.
“This research paper has brought into the spotlight themes that are consistent with those in which we have also been hearing from our allergic community and stakeholders,” says Holly Shaw, clinical nurse advisor at Allergy UK. “Food allergy is a concern due to the possible risk of a fatal anaphylaxis. This study reinforces the importance of work on allergy awareness and education, specifically in those people who are at greater risk, including those with asthma and a food allergy.”
Allergy case reporting
According to the Imperial College London researchers, better diagnosis and management of anaphylaxis could partly explain the decrease in deaths despite rising hospital admissions. However, many doctors are concerned that food-related anaphylactic deaths are being under-reported.
A 2021 survey from the Natasha Allergy Research Foundation revealed that some people see an allergy specialist within a week after an allergic reaction, but others wait for months, often with no support, due to long waiting lists for a specialist appointment. Some 74 per cent of those who had a serious reaction said they didn’t immediately get a prescription for an adrenaline auto-injector, and 79 per cent waited one month or longer for medication.
Stephen Holgate, professor of immunopharmacology at Southampton University and a trustee of the Natasha Allergy Research Foundation, says that it is imperative to understand the full scale of food allergies in the UK so that those individuals can get the care they need to prevent unnecessary anaphylaxis and deaths. “The lack of allergy specialists means that anaphylaxis is being underdiagnosed and underfollowed up; hence anaphylactic deaths, all of which are preventable,” he says. “This study only looked at UK hospital admissions, and we know that many people who experience a severe food allergy will be treated as an outpatient in A&E. Therefore, the true toll of severe and life-threatening food allergies in the UK is likely to be much higher, especially since anaphylaxis masquerades as other clinical conditions such as asthma, angioedema (rapid swelling underneath the skin) and urticaria (hives).”
The Natasha Allergy Research Foundation is calling for a national register of food-related anaphylactic fatalities to be introduced to provide more accurate information. “We would like to see a permanent register of food-related anaphylactic deaths embedded in the NHS. There is such a register already in operation, run by a team in Manchester, but this only has temporary funding,” says Tanya Ednan-Laperouse, who set up the Natasha Allergy Research Foundation with her husband Nadim after their daughter Natasha died having eaten a sandwich that contained sesame but didn’t require allergen labelling. “It is only by learning from the circumstances surrounding anaphylactic deaths that we can prevent others and learn how to manage food allergies more successfully,” Tanya Ednan-Laperouse continues. “A register, however, after an anaphylactic fatality is too late for that individual and their family. If we truly want to reduce the number of avoidable fatalities then we must prioritise reporting near-misses and learn from these in an active and responsive way across all aspects of daily lives.”
Allergy labelling legislation
From October 2021, new legislation will require food businesses to provide allergen labelling on ‘prepacked for direct sale’ (PPDS) food. PPDS food is packaged on site by a business before a customer selects or orders it on the same premises, such as a sandwich or salad. The legislation change is in response to a UK-wide review following the death of teenager Natasha Ednan-Laperouse from an allergic reaction caused by sesame in a PPDS baguette that didn’t require allergen labelling.
Recent research from the Food Standards Agency (FSA) has found that food businesses’ handling of allergens has significantly improved since allergy labelling regulations came into force in 2014. Some 95 per cent of food businesses say they have a written or informal policy on allergen labelling – up from 60 per cent in 2012. This includes a large majority of market traders. The new regulations in October 2021 will enforce consistent and accurate labelling throughout the food business industry.
“At the FSA, we want to make the UK a place where food is safe, where allergy information can be trusted and where food hypersensitive consumers are included in our food culture,” says Rebecca Sudworth, FSA’s director of policy. “We are really pleased to find evidence of a shift in business practices, where allergen management has become a part of the day job rather than an afterthought. But there is still much to do. That’s why we are continuing to work with food businesses to instil understanding of allergens, and why new laws are coming in to force later in the year requiring allergen labelling on food prepacked for direct sale.”
If a pharmacy customer believes they have reacted to something they’ve eaten, it is important that they speak to their GP and get properly diagnosed. Food hypersensitivity involves any unpleasant physical reaction after eating certain food, and there is a lot of confusion between food allergies and food intolerances – the former involving the immune system and the latter not.
“Food allergies are rising in the UK, but around a third of the population believe they have a food allergy when they don’t,” says Dr Vibha Sharma, consultant paediatric allergist at Royal Manchester Children’s Hospital. “Only around five to 10 per cent of the population have a genuine food allergy.”
While some people may recognise immediate food reactions (e.g. itching around the mouth, a skin rash) or signs of anaphylaxis (e.g. breathing difficulties, fainting, palpitations), some allergy symptoms and intolerances are more difficult to identify. “There are two different types of food allergies: immediate and delayed,” says Aneta Ivanova, paediatric allergy consultant at the Midlands Allergy Service. “Food intolerances can trigger similar gastrointestinal symptoms to those in delayed food allergies. The only proven way to distinguish between the two is for a specialist to take a detailed medical history and carry out investigations and allergy testing if necessary.”
According to Laura Phillips, paediatric allergy dietitian at Allergy UK, food allergy tests need to be interpreted by an experienced healthcare professional with experience of allergies. Some tests measure the levels of immunoglobulin E (IgE) in the blood – a type of antibody that indicates an allergic response. “Allergy testing for IgE-mediated (immediate) allergy is done by skin prick testing and/or blood tests, which test for specific IgE against a particular allergen(s), for example peanuts,” she says. “Oral food challenges (a supervised feed in a hospital or allergy clinic) can help confirm or rule out food allergy. But not all types of food allergy are diagnosed by clinical tests. Non-IgE (delayed) allergy diagnosis involves a trial of eliminating the suspect food from the diet over a period of time and then reintroduction, which should always be guided by a healthcare professional.”
The BMJ research revealed that cows’ milk allergy is now the most common cause of fatal food anaphylaxis in children in the UK. But cows’ milk allergy is often mistakenly considered to be mild and frequently outgrown, according to the Anaphylaxis Campaign.
In children who don’t outgrow their allergy, more awareness is needed around the potential severity of reactions to milk, particularly as it is so widely consumed and difficult to avoid completely. Older children with persisting milk allergy tend to also have other atopic diseases including asthma, which may increase the risk of severe allergic reactions.
Tanya Thomas, British Dietetic Association (BDA) spokesperson and registered dietitian, says that the pharmacy team should be aware that symptoms of cows’ milk allergy can be quick onset or delayed onset. “Common symptoms include vomiting, reflux, wheezing, back arching with feeds or shortly after feeding, colic, diarrhoea, constipation, feed refusal and eczema,” she says. “Community pharmacies should signpost suspected cases to their GP, who may refer patients on to NHS dietitian for dietary advice, or onto tertiary care as required. Dietitians can help with managing dietary restrictions and checking nutritional adequacy of restricted diets.”
People with food allergies will usually be advised to carry antihistamine and adrenaline auto-injectors with them at all times. Dr Sharma says that pharmacy teams can help to ensure that patients are being prescribed an appropriate non-sedating antihistamine. “Sedating antihistamines – such as chlorphenamine – are not good medicines for allergic reactions,” she says. “Anaphylaxis can cause breathing or blood pressure issues, leading to fainting, and chlorphenamine can also cause this, so it makes it harder to assess patients. Chlorphenamine can also cloud concentration and affect sleep patterns. People don’t realise the number of accidents caused by taking it.” As such, non-sedating alternatives are best.
According to Tanya Ednan-Laperouse, some patients find it difficult to obtain supplies of adrenaline auto-injectors, so community pharmacies should ensure that they have a regular stock. “Some people have to try many different locations and/or experience a wait of days or weeks for what is life-or-death medication,” she adds. “The same seriousness needs to be given to having adrenaline auto-injectors available as has been given to having defibrillators available across the country. Training pens also need to be given out so that family members and friends of the individual with food allergy can feel confident in using them. This will help to ensure correct usage when a life-or-death food allergy situation happens.”
Holly stresses the importance of advising customers about when and how to use their adrenaline auto-injectors and signposting to support organisations such as Allergy UK. “There’s an opportunity to educate the customer on device technique. They need to know to call for medical help early (ambulance: 999) and not to delay in administering IM [intramuscular] adrenaline for suspected anaphylaxis,” she says. “Where patients have a food allergy and asthma, education on asthma control is of key importance as this combination is the cohort of people that have less favourable outcomes.”
Raising awareness of allergy action plans, and sharing them with the appropriate people, is also crucial, according to Holly. These are an individualised written plan of care for allergy children and can help to inform and educate people in childcare and/or educational facilities that the children might attend so that they know what course of action to take in an emergency.
Educating young people about food allergy
While preschool aged children have the highest rate of hospital admissions for anaphylaxis, the death rate is highest in teenagers through to mid-adulthood, according to research published in the British Medical Journal (BMJ) in February 2021. The Anaphylaxis Campaign suggests that this could, in part, be due to a decrease in parental support as children approach or reach adulthood; more risk taking, including experimenting with new foods; travelling alone or with friends; reluctance to share information; and resistance to carrying an adrenaline auto-injector on them at all times.
“Community pharmacies can play a significant role in raising awareness of potentially serious food-related allergic reactions amongst teenagers and young adults,” says Aneta Ivanova, paediatric allergy consultant at the Midlands Allergy Service. “They could be equipped with informative leaflets on reactions and anaphylaxis caused by food allergy, which they can supply to teenagers and young adults when they’re collecting allergy medication such as antihistamines and adrenaline auto-injectors.”
The Food Standards Agency (FSA) ran its #SpeakUpForAllergies campaign in March 2021. As research shows that children and young people are at a higher risk of experiencing food allergy reactions, the campaign aimed to encourage young people to always speak to a restaurant about their food allergies, even if it’s a meal they’ve eaten before.
These messages are significant ones to reiterate to customers and Holly Shaw, clinical nurse advisor at Allergy UK, adds that it’s an important part of encouraging confidence in allergy management. “Teenagers and young adults need to learn to speak up at restaurants or at their friend’s house to whoever is preparing the food,” she says. “Hidden ingredients and cross-contamination are risks when dining out, so be sure to clearly explain allergies to takeaway staff, restaurant service staff or a friend’s parent. They should avoid sharing food or drinks unless they know what’s in them – a drink may have been contaminated with something their friend has eaten.”
Food businesses are legally required to make allergen information available when an order is placed, and when the food is delivered. However, people with food allergies should never assume a meal will be safe, as ingredients and recipes can change, as can restaurant chefs and staff. It’s important that the person serving them understands the individual’s needs and that they are not put at risk of an allergic reaction by miscommunication or cross-contamination of food.
The FSA is also advising young people not to only rely on allergen information provided online or through in-app messaging services. “Our research has revealed that young people are eating takeaways more often than before lockdown,” says Rebecca Sudworth, director of policy at the FSA. “With eating in being the new eating out, it is vital that young people with food allergies and their friends remember to speak to the restaurant every time they make an order.”
To support the campaign, the FSA created specific advice for teenagers and young adults.