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food allergies in the early years — Transcript

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0:05and as I said welcome to Dr Penny
0:08Barnard I don't know Penny if you just
0:09want to give yourself a quick
0:11introduction of course yeah so I'm Penny
0:14Barnard I'm a pediatric dietician um and
0:17I'm coming up to I think 30 years nearly
0:19working um in the NHS um the majority of
0:23those um years not all of them have been
0:26with um food allergy so as I'm sure you
0:28can imagine I've seen lot of changes um
0:31with how we treat food allergy um over
0:34those years and certainly the numbers U
0:36that we see with food allergy over the
0:38years so as well as um working for the
0:40NHS I do some freelance work um all of
0:44which are around um food allergy so I
0:47was delighted when nursery kitchen um
0:49contacted me uh to join them to try and
0:53um develop some information for
0:55nurseries for their Partners um around
0:58um allergies food allergy particularly
1:02and um obviously as a dietitian working
1:05in food allergy I'm just absolutely
1:07delighted that it's on top of um their
1:10agenda and everybody that's attending
1:12today obviously your agenda to think
1:15that um food allergy is important so um
1:18yeah I'm really hoping today you get a
1:21lot out of um this evening and please as
1:24Katherine says please do um file your
1:27questions at me at the end we will leave
1:29lots of um time for questions because I
1:31think that's really
1:33important super thank you
1:36penny so we will get started um and and
1:40part of the reason why we are working
1:42with Penny and um we have organized this
1:46webinar for you this evening on behalf
1:47of n nursery kitchen um in collaboration
1:50with Penny Barnard is because that we
1:52know that allergies are are complex
1:55they're really difficult to
1:56navigate um they're really unique to
1:59each child so we know it's not
2:00necessarily A one-size fits all approach
2:02which is what adds to the complexity of
2:04them and they're also a little bit scary
2:07it's quite scary when you are an
2:09earliest practitioner and you are in
2:10charge of children who um are suffering
2:13with allergies and some of those
2:14allergies might be quite severe
2:15allergies as well so we number one at
2:19nursery kitchen we really want to make
2:21sure that we are keeping children safe
2:23we really want to support you guys we
2:26know how scary it is we know how complex
2:28this topic is um and that's one of the
2:30reasons why we have collab collaborated
2:32with Penny we want to make sure that we
2:35are um more than just a food provider
2:37and we are supporting you with
2:39up-to-date evidence-based information to
2:40help navigate these complex areas as
2:43well um and we want to to pass that
2:46message on to you but also to reach out
2:48to parents and families who might also
2:49be struggling with this so it's really
2:51crucial that accurate information is
2:53available to to parents and carers um
2:56and also you as early as practitioners
2:58so that informed decisions can be made
2:59about children's food allergies and we
3:01also want to make sure that we are not
3:04um avoiding food in children's diet
3:07unnecessarily um because we know that
3:09there can be a risk then of nutritional
3:12deficiencies a lack of variety um in the
3:15child's diet which may lead to poor diet
3:17and growth um and we want to make sure
3:21that we are doing the very best for
3:23those children so that's really where
3:26this project with all with penny has
3:28started our allergy project
3:30um a little bit of information about
3:32Penny um further to her introduction
3:34earlier Penny graduated from the
3:36University of Sur as a dietitian um and
3:39has a PhD from the University of
3:41Southampton as well she's a registered
3:43dietitian with over 25 years experience
3:46as an NHS pediatric dietician and a
3:49specialist in pediatric food allery and
3:51gastroent enterology um I know P you
3:55work for the NHS as a pediatric
3:57dietitian and you have kind of weekly
3:59allery clinics as a consultant pediatric
4:02uh
4:03dietician um and you organize food
4:06challenges that are carried out on the
4:07children W and you also participate in
4:09freelance work writing articles lots of
4:12consultancy work presentations teaching
4:14mentoring around this topic so you're
4:18the perfect person to join us this
4:20evening um and we're so pleased to
4:23collaborate with you on this really
4:25important topic and as Penny mentioned
4:28she has been fantastic at supporting us
4:31with the development of a series of
4:33allergy fact sheets um which we're going
4:36to um introduced to you briefly this
4:38evening and Penny will talk about some
4:40of the key topics from each of those
4:43fact sheets um you may have already seen
4:46these fact sheets we've got um nine
4:48different fact sheets they're all listed
4:49here they are available to you as
4:52partners of us at nursery kitchen but we
4:54will also pop a link this evening in the
4:57chat box um to each of these fact
5:00sheetss so that if you haven't seen them
5:02you can have a look at them in detail
5:04tonight um and save those for a future
5:06dat as well but we've got um fact sheets
5:09on what is a food allergy the difference
5:11between immediate and delayed food
5:13allergies which Penny will talk more
5:15about this evening um what is a food
5:18intolerance and how that differs to food
5:20allergy and then also what is a contact
5:23reaction that's something different
5:24again um we've also got a fact sheet
5:27which covers key question and answers
5:30for early year practitioners so some of
5:32those frequently asked questions um that
5:35you as an early year practitioner might
5:37be coming across when you're managing
5:39all allergies in your settings um and a
5:42similar one for parents and carers as
5:44well which might be useful for you to
5:45share with your families um there's also
5:47a fact sheet on allergy testing there's
5:50one which covers 10 things you should
5:52know about food allergies and
5:54intolerances and also a summary document
5:57around what should you do if you suspect
5:59a child has reacted to a food so they
6:01will all be available to you going
6:03forward as fact sheets but I will hand
6:05over Penny to Penny um who will talk us
6:09through each one in in a little bit of
6:12of
6:13detail y over to you Penny lovely thank
6:16you um yes we'll we'll um briefly
6:20mention um some of the leaflets and go
6:22into a bit more detail in some of the
6:24others I think the ones that I think you
6:26might need um more information on
6:28because hopefully you've seen um them
6:30and if you haven't um not to worry so I
6:33think one of the really important things
6:34that Katherine said um a few moments ago
6:38that is food allergy is scary and it's
6:41scary for everybody um I know um from
6:44her point of view it must be scary for
6:46early year settings to have to um deal
6:49with food allergy more and more but
6:51equally from the um parents side it's
6:55really scary them having to choose a
6:58nursery and
7:00um for them to send their children um
7:02off to Nursery to be cared for by
7:04somebody else because quite often it's
7:07the first time um their child has been
7:10away from them for somebody else to um
7:14take responsibility um for their child's
7:17allergy so it is really scary for them
7:20and um I speak to parents most days
7:23about this and their
7:25anxieties and I think um the key thing
7:28here is um we're not expecting anybody
7:31in an early year setting to uh be able
7:34to advise parents on food allergy in a
7:37detailed way but it's just so important
7:40that when parents come to Nursery with
7:43their children with food allergies just
7:45a slight bit of reassurance that the
7:47nursery workers the key workers have
7:50heard of food allergy they know what it
7:53is they know the different types and
7:55that is just so reassuring for parents
7:57for them to think that you know these
8:00these people that the carers that I'm
8:02leaving my child with yes they do know
8:05something about food allergy and that
8:07gives them great confidence so so let's
8:10far away so um all importantly what is
8:13food allergy and I'm going to just this
8:15in in a nutshell really um for you to
8:18remember food allergy is an abnormal
8:21reaction to food but importantly it
8:24involves the nervous system the immune
8:26system sorry so um that's the key thing
8:30and that's the key thing difference
8:32between an intolerance and an allergy an
8:34allergy will involve um the immune
8:38system after that it starts to get a
8:40little bit more complicated and as you
8:43the majority of you will be aware there
8:45are two main types of food allergy one
8:49that we call um an immediate food
8:51allergy or an
8:53IG um mediated food allergy and the
8:57second type is the um more delayed type
9:00of food allergy or we call it a
9:03non-ig um food allergy and in the
9:06nursery setting you'll um come across
9:10both types of food
9:12allergy now I think maybe at this point
9:15let's talk a little bit about um
9:19expectations and how many children do
9:21you think will be coming through your
9:23doors with a food allergy and I know
9:26that you probably get far more children
9:29coming through your doors with a food
9:31allergy then actually probably do have a
9:33proven food allergy so there's a big
9:36study done a world ago called the Euro
9:38preval study um that looked at um the
9:42prevalence of food allergy by two years
9:44of age so that's quite a good age range
9:46for the early year setting so uh when we
9:49look at that data we know that um in
9:52that in the um the group that was
9:56studied the um allergy at two years had
9:59to be proven so that was either um that
10:01was normally with um allergy testing and
10:04we'll go into that in a little bit more
10:05detail or if not a food challenge and we
10:09know from that study that around 5% of
10:12children um under two will have
10:14developed to food allergy and very
10:17roughly we can split it into two half of
10:19those will have a non-ig um a delayed
10:22half of those will have an immediate um
10:25an IG type of allergy we also look they
10:29also looked at the type of allergies in
10:31those groups so we know in this um age
10:34group that the IG the immediate is
10:38likely to be egg it was predominantly
10:41egg peanut a little bit of milk and a
10:44few other um tree nuts maybe but it's
10:47predominantly egg and peanut and then um
10:50a little bit of of milk and other um Tre
10:53nuts I would suspect since the study has
10:56been done because it was done a few
10:57years ago now um the um incidence of um
11:01IG milk allergy um will be rising if we
11:05look at the other half the other two and
11:07a half% the non-ig the um delayed
11:11allergies it was predominantly milk it
11:13was predominantly to milk so a non-ig
11:16milk allergy so if we think of that 5%
11:19of children under two so um in um in a
11:24in a setting where you have a hundred
11:25children five of those will have a
11:27proven food allergy we know because the
11:30uh participants were sent questionnaires
11:33then in actual fact 35% of them thought
11:35their children had a food allergy so
11:38that's a huge huge
11:40discrepancy so um many of those children
11:43of course will be coming to the early
11:45year setting and saying their children
11:48have a food allergy whether it be a
11:50delayed or immediate so um it's kind of
11:53trying to sift through this information
11:56and um really find the children that
11:59have um the food allergies and that's
12:02why throughout our documentation we talk
12:04about confirming a diagnosis it's
12:07important that children you're looking
12:08after um and you're you're wanting to do
12:11the best for have a confirmed food
12:13allergy and that's um so they get the
12:16best treatment but also um to protect
12:19the child they only really as um
12:21Katherine's already touched on it's
12:23important that they're only on
12:24restrictive diets if they need to be um
12:28and that's important
12:30um so that's a little bit about food
12:32allergy and that's kind of covered um in
12:34this first fact sheet here I've just
12:36waffled on on my own um bit so um let's
12:39move on um to the main differences um
12:42between um the the types of allergies
12:44we'll fly through this because um in the
12:46leaflet there's some really nice tables
12:48that nursery kitchen have um put
12:51together um explaining describing the
12:53differences so let's look at um IG
12:56mediated food allergy again reminding
12:58you that's the immediate so um symptoms
13:02here as the name suggests are immediate
13:05and we normally say symptoms will
13:07develop within two hours of exposure of
13:09the food um but realistically it
13:12normally happens within 30 minutes so it
13:14really is quickly so patients I get to
13:17see um that come and see me say oh um my
13:20child um had a meal and the next morning
13:22they woke up with a rash that's unlikely
13:25to be an immediate reaction because it
13:27wasn't within 2 hours of devel of eating
13:30the
13:31food um now importantly with the IG
13:35immediate reaction symptoms can be
13:37severe and importantly for early year
13:40settings they can be
13:42life-threatening um and this is where
13:44food allergies become very very scary
13:47you will have children in your settings
13:49that have emergency medication which
13:51will come through um which we'll go
13:54through with you later um um but it's
13:58really important to put it into
14:00perspective since I've been practicing
14:03um in the UK um I've only known one
14:07child one too many I absolutely
14:10understand that but I've only known one
14:12child um as a as an as an infant under
14:15one um that's died of anaphylaxis and
14:18that was a long long time ago about 22
14:21years ago um and that was in a nursery
14:23setting
14:24unfortunately um but and the um baby was
14:28given um um the wrong bottle they were
14:31given a bottle of normal formula um not
14:33their specialist in formula and they had
14:36Anais and unfortunately um I died from
14:40that um but as I say anaphylaxis does
14:44occur but in this age group um
14:48luckily um it's not often um
14:53fatal it's difficult isn't it because um
14:56in the Press at the moment there's a lot
14:58about food food allergy and I think Adam
15:01Fox is actually on the Telly this
15:02evening talking about anaphylaxis and
15:04fatal anaphylaxis because there has been
15:07several cases um in the UK um recently
15:11where our teenagers and our young people
15:13um have died from anaphylaxis and that
15:16tends to be the age group where um it's
15:20it's really risky so I'm not downplaying
15:23anaphylaxis in infants but hopefully
15:25what I'm doing is trying to demonstrate
15:27to you and illustrate to you that it is
15:30very rare for a baby an infant to die of
15:34anaphylaxis although we talk about it a
15:36lot and of course we always have that
15:38emergency medication to if it does
15:41happen if analis does occur for it to be
15:44treated so yes symptoms can be severe
15:47and
15:48life-threatening um luckily this type of
15:50allergy can be tested for and we'll go
15:52for that in a little bit more
15:54detail um and the symptoms can also be
15:56treated with the antihistamine um and
15:59adrenaline as we've just talked about
16:02and um every patient with an IG mediated
16:07food allergy that comes to your early
16:09year setting should have an allergy
16:11action plan um and that should have been
16:13provided to them by their allergy
16:15specialist doctor um dietitian or GP and
16:21um reactions can happen to trace tiny
16:25tiny amounts of food or larger amounts
16:28so reactions can happen because you've
16:30got it on your hands and you haven't
16:32washed your hands before serving a meal
16:35to um a little one with a food allergy
16:38or even you know doing playing with them
16:40Etc if you've got something on your
16:42hands so Trace Amounts in contrast then
16:45a delayed reaction normally happens
16:48after ingesting a food the symptoms
16:49occur after two hours and can be up to
16:52two or three days after eating the food
16:55and that's why it's so difficult um to
16:56get a firm diagnosis with these um types
17:00of allergies um but these um symptoms
17:03and allergies tend to be milder and are
17:06not lifethreatening um and unfortunately
17:09they can't be tested for there there is
17:11no test like there is with IG it's just
17:14a detailed history um and avoidance and
17:17reintroduction um and the symptoms
17:20generally can't be relieved with
17:22antihistamine um and they tend to not
17:24have um emergency action allergy actions
17:27plans because they won't have
17:29adrenaline and um again similar to ig
17:33reactions can happen to trace or um
17:36larger
17:37amounts so there's some common symptoms
17:40there of um both the types of um
17:43allergies and you can see there it kind
17:46of demonstrates that with the non-ig
17:48type the delayed type A lot of these
17:50symptoms are related to the gut whether
17:52it's vomiting or diarrhea or tummy ache
17:54or constipation or reflux or
17:57uncomfortable all those sorts of things
18:00um compared to with the IG where the
18:03symptom can be the skin the gut um the
18:06Airways lots of different um symptoms
18:08going um on there should we move on
18:12Katherine to the next
18:14slide Catherine sh lovely so um I'm not
18:18going to talk about food intolerance too
18:20much but let's just um put the
18:22definition of food intolerance um into
18:25perspective alongside food allergy so
18:27let's just remind ourselves food allergy
18:29is an abnormal reaction to food that
18:32involves um our immune system with a
18:35food intolerance is an abnormal reaction
18:37to food but it doesn't involve our
18:40immune system okay so a few examples of
18:43that or an example of that that you were
18:45likely to have heard of is um lactose
18:48intolerance where um somebody might have
18:52um a reaction to something that contains
18:55lactose which is the milk sugar um the
18:58sugar in milk and the immune system
19:01isn't involved it's because um the sugar
19:04in the milk the lactose isn't digested
19:07because they haven't got the lactase
19:08enzyme so sugar is attracted into the
19:11gut sorry water is attracted into the
19:13gut because of the sugar and it causes
19:16diarrhea and they get um severe diarrhea
19:20so um lot of misuse of the word of food
19:23intolerance and lactose intolerance by
19:26parents and equally healthare Care
19:28Professionals I still get lots of
19:30referrals from GPS who say this child
19:33has lactose intolerance they haven't got
19:35lactose intolerance at all they've
19:36probably got a milk allergy but it's not
19:38a lactose intolerance so um yeah so
19:42really I guess what I'm saying here you
19:45probably shouldn't come across too much
19:46food intolerance it tends to be um in
19:49the older years um as they get older
19:52unless somebody has got an absolute
19:54genetic lactose intolerance which is
19:56very very rare
19:59okay I think that's all I think I need
20:00to say about food intolerance if anybody
20:02has got any other um questions on that
20:05we can answer them in question time so I
20:08think this is a really important one as
20:10well because it could kind of get
20:12confused in the mix of
20:14everything um and again um as Katherine
20:18said I do um a weekly Clinic with um a
20:21consultant um and we get lots of
20:24referrals for this child has a severe
20:27reaction to
20:29strawberries um to
20:31raspberries to spinach to OB all these
20:35sorts of things even to hum us and um we
20:38have to sift through the
20:39symptoms and decide whether we actually
20:42do think it's an allergic reaction or
20:44not CU quite a lot of the time some of
20:47these children are actually just having
20:49a contact reaction for for lots of
20:52different reasons and it tends to be in
20:55children that maybe do have a sensitive
20:57skin so maybe have eczema um but it's
21:00not exclusive to children with sensitive
21:02Sim but it certainly is very common with
21:05um children that suffer with ECA so it's
21:07simply because the um the food has
21:11touched the skin and the Skin's
21:13sensitive and it's aggravated it and it
21:15could have aggravated it for a lot of
21:17reasons it could have been a very acidic
21:19food it could have been a very salty
21:21food or the food itself when it's um
21:25eaten is a food that's um high in um
21:28histamine itself and when we have an
21:30allergic reaction the allergic reaction
21:33is caused by the release the symptoms
21:34are caused by um the release of
21:37histamine so if you like when we eat a
21:40food that's high in histamine for some
21:42people it kind of mimics that reaction
21:44you get a little bit of redness but
21:46there are some key things that would
21:48lead us to think that it's a contact
21:51reaction so apart from the very common
21:53foods that do it and whilst I read them
21:56out you'll be thinking oh yes yes we've
21:58definitely got little ones at Nursery
21:59that for example they have tomato oine
22:03spinach orange lemon juice common in
22:06like things like hummus lemon juice is
22:08used in a lot of things strawberry
22:10raspberries they get redness um around
22:13the mouth so this um leaflet really well
22:18I think um talks you through that and
22:22tells you um the kind of things you're
22:26looking for if we think it is a content
22:29reaction so type of things the redness
22:31is very much isolated to um the face or
22:37particularly where the food is touched
22:39so often parents will then say oh no no
22:41no no no no but they got a bit of
22:42redness up here or or you know their
22:44hands were really red as well so no no
22:46no no definitely an allergic reaction
22:49but when we talk to them further how was
22:51the child fed do they like eating from a
22:53spoon oh no no no they like to feed
22:55themselves and are they a very clean
22:57eater goes every everywhere and of
22:59course the children move the food around
23:01their face so it might not just be where
23:03they're eating and they get it all on
23:05their hands and often children that are
23:07in those like all-in-one um bib type
23:10things it's very clearcut you can see it
23:12from the elastic almost from around the
23:14wrists um the the um the contact has
23:18gone red from the hands so that's a
23:20Telltale sign with an allergic reaction
23:23generally but not all the time we are
23:25looking for um a reaction Elsewhere on
23:28the body if we're talking about a rash
23:30it you know there might be a rash um on
23:32the Torso on the legs on the tmy on the
23:34back anywhere really rather than just
23:37localized um to the contact
23:39areas um the the area um will look very
23:43red and angry um and it tends to subside
23:47by itself um and we all just recommend
23:51that um the food is wiped away quite
23:54quickly um after eating carefully so
23:57you're not adding to the sore is the
23:58rubbing you know with a flannel or or
24:01something like that um and it it tends
24:04to subside itself but it's fine to give
24:07a little bit of antihistamine um if it
24:09doesn't importantly um also is the child
24:13generally isn't phased by it they don't
24:15start crying they don't start screaming
24:17they don't become agitated they just
24:20carry on eating and they're happy you
24:22know as Larry it's normally when Mom
24:24starts to get a bit fractur and say are
24:26you all right darling you know thing
24:29that sometimes they can get a bit
24:30annoyed or when the food is taken from
24:33them and then they start get crying and
24:35getting angry and getting redder and a
24:37bit um more unhappy but but it tends you
24:40know not to phase them in contrast
24:43therefore um where it's not likely to be
24:46an allergic reaction as I've said where
24:47the rashit might be elsewhere so you you
24:50look oh gosh yes nasty um redness
24:54irritation around the mouth and then in
24:57actual fact you know you might look down
24:59the the T-shirt down the back and and
25:01the rash has spread that's not likely to
25:03be a contact
25:04reaction
25:06um oh sorry about
25:11that
25:22um sorry um and um with an allergic
25:27reaction normally the child becomes
25:28quite distressed um might start
25:31scratching um becoming um very irritated
25:35crying upset um you know scratching um
25:39all
25:40over and quite often the symptoms don't
25:43resolve um by themselves either um some
25:48antihist mean is normally um needed um
25:53to um deal with those symptoms or
25:56another important thing is if the
25:59symptoms de what we call develop so um
26:03rather than than just um having this
26:06isolated redness they might start to
26:08have a little bit of a cough a new cough
26:11that develops um or um as I said they
26:15get agitated or they start to um get
26:18puffiness um that's not normally
26:21Associated uh with a contact UM reaction
26:24so I'm sure again you've seen quite a
26:26few contact reactions in the in the um
26:29Nursery setting and again you don't
26:32necessarily have to avoid that food that
26:35um that reaction the contact reaction
26:39isn't harming them it's not necessarily
26:41doing them any
26:42harm um you know if the food's just
26:45wiped away and it self-resolved there's
26:47no reason why the child needs to avoid
26:49that food unless obviously the family
26:52particularly want them
26:54to should we move on to the next one
26:57sure lovely oh yes allergy testing so I
27:01I briefly
27:03um touched on this already so allergy
27:07testing um is really important for a
27:10media or IG mediated food allergies and
27:13basically there's two types of testing
27:15here we have um a blood test which is
27:18called specific IG um where we can um
27:22measure anything really and it goes off
27:24to a lab um the child's blood is taken
27:27it goes off to lab and we normally get
27:29the result within about 3 to four
27:31weeks um in contrast um and you can take
27:35antihistamine as well for that type of
27:37allergy testing so for example this type
27:40of year with the slightly older children
27:42so Pro I'm not sure what age um the
27:46audience the children you'll be looking
27:48after will go up to but children maybe
27:50that have highy fever type symptoms or
27:52are taking um antihistamines every day
27:55for blood tests they don't have to stop
27:57their antihistamine
27:58in contrast to the um what we call skin
28:01prick testing which is where we put a um
28:04a drop of reagent on the skin and gently
28:07prick the skin and then what we call a
28:09hive or a little bump um appears and we
28:12measure that bump against a control and
28:15a positive and we can um get an
28:18assessment of allergy from that both
28:20types of um food allergy are accurate
28:24and um I use them both I think out of
28:27preference it would always be skin prick
28:29testing um why because um we get the
28:33answer straight away we take a history
28:35there's me there's the doctor we take a
28:37history we decide what we're going to
28:39test for we test for it um and we have
28:42the result and we can give a um a plan
28:45and we can give you an allergy action
28:46plan we can sort your medication and um
28:49you know it's like a One-Stop service in
28:52contrast to a blood test where you yes
28:54you still have me and the doctor and we
28:57take a history
28:58and the Bloods can be taken but then we
29:01can't really give you an action plan
29:03because we don't know the results um and
29:05we can't set you medication because we
29:07don't know the results so always a
29:08second appointment there is needed which
29:11kind of stretches it out a little bit
29:13but it has its place particularly in
29:14primary care where your GP could have
29:17take a blood test to see um if there was
29:20any possible um um allergies
29:24there um brief briefly said about the
29:27anti so antihistamine can be taken when
29:29we do um blood tests but not with skin
29:32prick testing which can be a
29:34disadvantage I think they're both pretty
29:36invasive um children don't particularly
29:38like having them done so they don't like
29:40having the skin prick testing done and
29:42they don't generally like having their
29:43bloods done um so I would say you know
29:46there's not one that's better than the
29:48other really um yeah some some little
29:52ones absolutely ha it and and it and
29:54it's heartbreaking really because we
29:55know they've got to consistently come
29:57back for repeat testing maybe a year
29:59later two years later and we're um
30:02hoping as they get older that it becomes
30:04easier for them and and it generally um
30:07does so um in total contrast that is to
30:11non-ig or the delayed type of food Alles
30:14where we don't have a test to um prove
30:18whether that child or help the diagnosis
30:22um of a non-ig a delayed food allergy
30:25which is which is um where I think such
30:28a lot of the overdiagnosis of non-ig
30:30food allergy occurs um because it's all
30:33done via taking a detailed history and
30:37then cutting food out of the diet but
30:40importantly putting them back in again
30:42to check that that allergy is confirmed
30:46now with a lot of people that seems
30:48quite mean putting the food back in
30:50again but um it could just be a
30:52coincidence that by taking these Foods
30:54out particularly for milk that the
30:56children's symptoms um actually do um
30:59improve and we find that a lot so it is
31:02important that there is that um
31:04reintroduction of the food um to try and
31:08a diagnosis there again children with
31:10non-ig food allergies won't have an
31:12allergy action plan because they tend to
31:14not come to hospital or their care tends
31:17to be done in primary care they may have
31:19a dietitian in a hospital but they tend
31:21to not have an allergy team unless
31:24they've got what we call mixed where
31:25they might have a non-ig and an IG
31:28um food allergy together so they they
31:30probably will have an allergy team there
31:33so they're very much looked after by
31:35their GP um Andor a
31:37dietician or maybe their health visitor
31:40so sometimes um I would imagine for the
31:44um early year settings it's really
31:48difficult for you to get um clear
31:50information and if you like confirmation
31:52I think that's probably a better word
31:54confirmation of these allergies um and I
31:58think that was one of the questions in
31:59in uh one of the leaflets was I suggest
32:02that um you know you you can ask for
32:05written if you like letter from the GP
32:07to say the child has um a non-ig milk
32:10allergy or um you know they their letter
32:14from the dietician if they've seen a
32:16dietician or um The Clinic appointment
32:19letter just to show you that there are
32:21Health Health Care Professionals
32:23involved and yes this child does have um
32:27know an allergy that does need attention
32:30does need um looking
32:32after importantly um there are a lot of
32:37tests out there um that um aren't
32:40reliable and if you remember I keep
32:42saying this um an allergy is an adverse
32:45reaction to a food that involves the
32:48immune system so if you think if we look
32:50down that um list of alternative allergy
32:53tests hair analysis for an example well
32:56how on Earth just look looking at hair
32:58analysis is anything to the immune
33:00system going to be involved by doing
33:02that it's not um so again um another one
33:06that's commonly done is looking at IGG
33:09um antibodies and we all have IGG
33:12antibodies to food so if I'd had a blood
33:14test for IG you could say I have food
33:17allergies because I've got some IG to
33:18food and I don't have any food allergies
33:20so if you remember with the immune
33:23system um it's IG e um not g and there's
33:28a pleora of of tests there um that
33:31really don't have any scientific basis
33:33for helping us diagnose um a food
33:35allergy even though on social media Etc
33:39they are widely um recommended so again
33:43just you know if you have maybe um
33:45little ones come to your Nursery
33:47settings that the mom says oh yes we've
33:49sent away you know for this test that
33:51test it was hair analysis it was kology
33:55they've gotten they give you this list
33:57of all the things their little ones
33:58allergic to um you know maybe a
34:00conversation um would be helpful saying
34:03or hand them the leaflet maybe to
34:05suggest that maybe alternative tests um
34:08are are more
34:10valid it used to be very much um in in
34:13Years Gone by that a lot of these tests
34:16were done if you like in private clinics
34:18so private allergy tests and and Clinics
34:22were Al always thought a no no but that
34:25has very much changed a lot of allergy
34:27Care Now now is done in primary in Al in
34:30private allergy clinics because of the
34:32long on NHS waiting times really um and
34:36I know you know from a lot of my
34:38patients um that I see um out of my NHS
34:41role that some of them are waiting like
34:43a year a year and a half for um allergy
34:45testing and Allergy Clinic appointments
34:48so you know certainly um private clinics
34:51there do have a role to play as well so
34:53if they if if um a little one says
34:56they've been to a private Clinic don't
34:58assume that it's one of those
34:59alternative tests it may well not be so
35:02it's always worth
35:03checking so uh we have another leaflet
35:07um that um that nursery kitchen have um
35:10put together that a that talks you
35:13through what to do if um you have a
35:15child that you think is reacting to a
35:17food and it really summarizes nicely
35:19what we've already gone through in a
35:21nice flow diagram for um a contact
35:24reaction um a a food allergy and then
35:27whether you think it's an immediate or a
35:29delayed food
35:32allergy move on super yely great thank
35:37you Penny um that was so useful and I
35:40think almost you know obviously your
35:42knowledge is incredible on this topic um
35:45you it's really helped to highlight kind
35:47of how complex this area is but putting
35:50it in that context of uh earlier
35:52settings is really helpful um and and I
35:55think you know for me one of those R
35:56standout fig from that research project
35:59that you talked about right at the
36:00beginning is fascinating to see that
36:0335% of parents perceive their child to
36:06have a food allergy and in actual fact
36:08when it's investigated and confirmed it
36:10was only 5% that had a true food allergy
36:12so I think that really demonstrates
36:14actually on the ground perhaps what a
36:16lot of earliest practitioners are facing
36:18when parents are coming to them saying
36:20yes you know my child has a food allergy
36:21and we know that that may not always
36:25NE oh
36:33Catherine I've lost you a little
36:41bit Catherine can you still see
36:47me don't know where she's gone let me
36:50um let me see what's
36:55happening do you want to ask if anyone's
36:57getting got any questions to ask Penny
36:59while we try and find my Katherine's
37:01gone oh
37:04yeah um so if anyone's got any questions
37:07um either put them in the chat I'm back
37:10oh you're back perfect sorry I've not
37:13sure what happened
37:15there um but yes thank you so much Penny
37:18I think that that was really useful um
37:20if yeah as Hannah said if anybody has
37:22any questions we're now going to open it
37:24up to question and answers so you're
37:26very welcome to pop any questions that
37:29you have into the chat box um I'm going
37:31to get started Penny if it's okay with a
37:33couple of questions that came in a
37:35little bit earlier on um so we have one
37:39question um which asks a little bit
37:42about cow's milk allergy um and in the
37:47same way that it's possible for a child
37:49to react to fresh milk but they may
37:51tolerate cooked milk particularly if
37:54it's in a matrix with wheat or something
37:56like that in it pancake or a muffin or a
37:58biscuit for example is it possible for
38:01children to
38:03tolerate cooked or heated or melted
38:06cheese but react to ready to eat cheese
38:10and and if so why would that be y that
38:14is possible so um sometimes with my
38:16patients I do suggest they do heated or
38:18baked cheese first um and then move on
38:21to what I describe as cheese as a picky
38:24food or grate it onto the top of
38:26something that hasn't been he
38:28and it's the exact same Theory as with
38:31milk and heated milk because obviously
38:33cheese is just milk really um so the
38:35theory behind it is um milk contains
38:39lots and lots of different proteins not
38:41just one and with a child would never
38:44quite know which of those proteins
38:45they're allergic to unless they've had
38:47very very detailed um tests which they
38:50tend not to have so they could be
38:52allergic to any one of the proteins or
38:54more um in the milk or cheese um now
38:59those proteins when we heat them um if
39:02you like they change okay they might
39:05make change they might change in shape
39:07so they become less allergic so when we
39:10have it in the heated form whether it's
39:12milk or exactly the same with cheese
39:15they're the same proteins in there um
39:17the confirmation if you like changes it
39:20becomes less allergic and the child can
39:22tolerate them better than when they're
39:25unheated um but hopefully by having that
39:28heated milk or cheese um over time
39:31whether that's a week or whether it's
39:33two weeks or whether it's months they
39:35should then be able to go on to develop
39:37what we call tolerance um to the
39:40unheated um milk again it it's I have um
39:44occasionally a patient that top of for
39:47example tolerating milk after milk
39:49allergy they go on to full fat cow's
39:51milk CU they're over one and they can't
39:53tolerate it but if I ask Mom to heat
39:56that milk first first before giving it
39:59them to drink cool it down they can then
40:02tolerate it so often we only have to do
40:04that for a couple of um a a couple of
40:08weeks and then M can stop heating it and
40:10the body's got used to that protein and
40:12then they can tolerate it unheated but
40:15it's the same concept the heat just
40:17changes the structure of the protein in
40:20the food and that and that could be egg
40:22it could be milk it could be cheese it
40:24could be anything um not anything but
40:26classic milk and cheese and they become
40:29less
40:30allergic or less allergenic as we call
40:32it yeah super thank you um brilliant
40:36thanks for that answer um we've had
40:38another question as well um which is
40:40less for you Penny actually more one for
40:42us to answer from uh nursery kitchen
40:44perspective but somebody asked whether
40:46we at nursery kitchen can confirm
40:47whether our menus are free from may
40:50contain nuts any products that that
40:53state that on their food labels they may
40:55contain um and if so is there anything
40:58in writing that we can pass on to
40:59parents to confirm this um and yes I can
41:02confirm that all of our products um are
41:06free from anything that may contain nuts
41:09obviously none of our ingredients none
41:11of our dishes contain nuts but we are
41:12also really careful when we are
41:15procuring and when we're sourcing
41:16ingredients for all of our dishes um
41:19that we are are clear that none of those
41:22products will have that on their label
41:24so none of the products state may
41:26contain nuts
41:27um and we have a fantastic procurement
41:29assistant Maria who is in charge of
41:32procuring these ingredients um all of
41:34our ingredients from suppliers and
41:35that's one of the the things that we're
41:37really really strict on so nothing will
41:39ever contain nuts or ever have a
41:41statement that says may contain nuts and
41:43if it's helpful then yes we can
41:45absolutely put something in writing to
41:48you so um please do always reach out if
41:51you want a statement from us that you
41:52can pass on to parents so that they get
41:54some reassurance around that as well so
41:57hopefully that helps to answer that
41:59question um we did we have we've had
42:03conversations about it as well haven't
42:04we about um may contain and its
42:07relevance and its importance so yeah
42:10it's great it's on your agenda and do
42:13you want to expand on that at all penny
42:15around the the may contain those more
42:18kind of precautionary food labels I know
42:20it's a complex it's a really complex
42:23topic because um there's no legal
42:26require ments and that is why it's um so
42:30complicated there's no legal requirement
42:32for any company to put precautionary
42:34allergen labeling on so some companies
42:37will um choose to put it on but some
42:40companies won't choose to put it on so
42:44those companies that haven't put it on
42:46doesn't necessarily mean that there's
42:49no risk that there contamination of
42:52their Foods they just haven't put it on
42:55so it is a very difficult topic and
42:57Studies have been done looking at foods
42:59that have precautionary allergen
43:01labeling and don't have precautionary
43:03allergen labeling and in fact both
43:05groups are can be contaminated with
43:08allergens so um that's not particularly
43:11useful information for parents but it
43:15does help put things into perspective
43:17that you just have to be careful and
43:18have the allergy action plans and your
43:20medication there to hand because um yeah
43:25you you never 100% no we know there's
43:28more riskier Foods we know that biscuits
43:32um you know cereal products chocolate
43:35sweets are the highrisk food for may
43:37contain and particularly chocolate um
43:40you can't unless there's a chocolate
43:42just making dark chocolate um no
43:46chocolate company tends to say um it's
43:49free from chocolate because it can't be
43:51unless they close the factory down
43:53between making their milk chocolate and
43:54their dark chocolate for 3 Days to clean
43:57and dry it's the drying of the
43:59Machinery um and that's not going to
44:02happen so yeah so you you will notice
44:05even with some dark chocolate that it's
44:07not in the ingredients list that may be
44:10may contain milk and and that's why
44:12because they can't
44:14guarantee it's it's not milk in there
44:17yeah not there super thank you Penny um
44:21we have a question from Frankie um she
44:24says I have a question around the skin
44:26prick Al test so if if they have a
44:29reaction to an allergen test would this
44:32affect the results of different allergen
44:35tests after the
44:37reaction does that make sense to you no
44:40I'm not quite sure on that one um
44:42Frankie I don't know if you're there and
44:43you're able to turn your microphone on
44:45and
44:46clarify that question for
44:49us so um yeah if she
44:54can if we have an allergic reaction
44:57action so for example if we have a
44:58severe allergic reaction you have to
45:00come to any um and then you come to the
45:02ward and you you have all your work up
45:05Etc um lots of parents get a little bit
45:07despondent because they're told they
45:09can't have allergy testing for a while
45:11and that's true we tend not to test for
45:14um for allergy within six weeks of
45:17having a severe allergic reaction okay
45:20because obviously their antibodies are
45:22going to be massive we we need the we
45:24need whatever's happening in the immune
45:26system to calm down um but I don't think
45:29that's what she's asking
45:31um Wonder skin so my question basically
45:36um I um I had a little boy he went and
45:38had skin bre testing done um and he
45:40reacted to several things um and one of
45:43them was a dairy allergy what I wanted
45:45to know is as he had the reaction on the
45:48skin PR test to the dairy allergy and
45:51then he then responded to three other
45:53things after the dairy allergy did the
45:56dairy skin prick test paint the rest of
45:58the
46:00results no so the reaction that it
46:03caused through the dairy allergy
46:05wouldn't then have caused a reaction on
46:07other
46:08allergens on on the test on on the skin
46:11test no no they're all very
46:14individual okay perfect thank you yeah
46:18yeah super thank you Penny if you think
46:22Frankie he also would have had a
46:24positive and a negative which were
46:26always comparing it with so the negative
46:29obviously should have been nothing there
46:30and he should have had a reaction to the
46:32positive so that's kind of what we're
46:35comparing the milk against and all the
46:37others should have been different or
46:38negative so but they don't affect each
46:42other hopefully that
46:45clarifies thank you um another question
46:48for nursery kitchen team which I'm G to
46:51Ping your way Hannah um I have a child
46:54who can't have lentils or beans Dairy or
46:57soy um obviously a lot of your meals
47:00have lentils or beans are there any
47:02plans to have more food without those
47:05ingredients as he enjoys eating the same
47:07as his
47:10friends um let me unmute myself so
47:13that's it's an interesting conversation
47:16we have at nursery kitchen all the time
47:18um is I guess from Katherine's point of
47:21view and you'll be able to talk about
47:22this more as ensuring that we have those
47:25iron rich prot so enrich Foods within
47:29dishes so you can get that from lentils
47:31and beans um versus not having them in
47:34so the child doesn't necessarily get the
47:36right protein so that is the reason why
47:39in a lot of the veggie dishes obviously
47:40we're adding them into our dishes um but
47:44and we actually had a conversation
47:45around this today with our development
47:47chef of how do we how do we have a
47:49balance on our menus where we've got
47:51some dishes that don't necessarily have
47:52all those beans but then we still need
47:54to be able to provide that source of
47:56iron rich foods um so it's something we
47:59debate all the time I know in the past
48:01we probably had dishes that don't
48:03necessarily have as many of those things
48:04in them and we've introduced them more
48:06to be able to hit that um nutritional
48:09guidance that we have um so It's Tricky
48:12I guess you know some of the pasta
48:14dishes don't necessarily have them in
48:17but then they may have dairy so it's
48:18it's definitely something that we talk
48:20about all the time and we need to have a
48:22level of balance on our menu I don't
48:24know if you want to say anything about
48:26that Catherine cuz know it's you know
48:27it's something you're really um
48:29passionate about and P is another one
48:31isn't it that's getting more and more
48:33common with little ones it seems to
48:37absolutely and we are we are hearing
48:39that more and more um and it's it's that
48:41difficult balance exactly like Hannah
48:43said OB we need to meet the nutritional
48:45uh requirements and we have quite tight
48:47nutritional guidelines that we stick to
48:49with all of our dishes because we know
48:51that protein and particularly those iron
48:53rich sources of protein are really
48:55important for children's development my
48:57question in regards to this child in
48:59particular is are they vegetarian um if
49:02they can have meat or fish as their
49:05option for protein and iron rich food
49:07then that might be a good alternative if
49:09they are allergic to things like beans
49:12and the lentils the soyer um so in which
49:16case then you know that would that would
49:17solve that problem if they can't have
49:20any meat or fish or beans pulses or
49:24lentils then you know that's a really
49:26different difficult diet to manage or
49:28they can have meat okay that's good um
49:32yeah that that would sort of be my go-to
49:34for that child then for those iron rich
49:37foods so rather than having choosing
49:39those the ing those dishes that we add
49:42lots of beans and pulses and lentils in
49:44um the meat Alternatives would would be
49:47um well the meat dishes would be a good
49:50option for that child um and there
49:52should be plenty of those on there on
49:54our menus that don't Al so contain beans
49:57and pulsers and lentils um that you that
50:00you could choose
50:02from
50:04um for nursery kitchen oh we'll come to
50:07that question sorry somebody else so I
50:08hope yeah I hope that answers your
50:10question it's like Hannah says it's
50:11difficult for us we have we have tight
50:13really tight nutrition guidelines that
50:14we need to stick to um but we're always
50:16really happy to discuss individual um
50:19children if you have got really
50:20difficult allergies to manage so please
50:22do always come to us with those
50:24questions because that's exactly what
50:25we're there for
50:27um penny I'm going to with through a few
50:29more um we've got one for you can a
50:32child have a contact reaction to a dish
50:35one week but when they have it again for
50:37example a few weeks later they may not
50:39have that contact reaction
50:42again yes and no I mean I I don't think
50:45there's any particular answer to this
50:47but yes I mean contact reactions when we
50:50have um a food allergy every time we
50:53have it we should have a reaction um you
50:55know it it doesn't allergies don't
50:58happen one day and not happen the next
51:01but with contact reactions it can be a
51:03little bit different I would say yes
51:05they can have it it might depend how the
51:08spinach is cooked for example or um how
51:11if the fruit is cooked or not cooked or
51:14how acidic the food is or how much salt
51:16is in there but yeah I would say
51:18generally yes and they could or it could
51:21also depend on that child's skin
51:24condition of the skin that day so if
51:26they have a sensitive skin or they've
51:29just had an eczema flare for example
51:31they're going to be more sensitive one
51:33week than they might the next or if
51:35their eczema's quite good and they've
51:37got lots of cream on that day because
51:38they're using their rolant well they
51:41might not have a reaction because in
51:43actual fact the food's not touching the
51:44skin because there's lots of emolient
51:46there acting as a barrier and that's one
51:48of the things we do say with um contact
51:50reaction sometimes it's a good idea to
51:52put a barrier cream on and maybe
51:54Vaseline for example to stop the food
51:56coming into contact with the skin so
51:58yeah it can be a little bit up and down
52:00with contact
52:02reactions super thank you Penny um we've
52:06got a another question for the food team
52:08um so with some of your dishes they just
52:12have cheese on the top could there be an
52:13option to have the dish without the
52:15cheese topping so it can be offered to
52:17children with a dairy
52:19intolerance Hannah do you want to start
52:22on that one yeah it' be interesting to
52:24know which dishes specifically cu
52:26because again this is something we talk
52:27about often because we obviously offer
52:29cheese as a side dish as well um so it's
52:33definitely something we can look into um
52:35but if there's specific dishes um please
52:38please put them in the chat and then we
52:40can take that away and talk to the rest
52:42of the team about
52:43it yeah absolutely and again you know we
52:46always welcome feedback like that
52:47because if there's changes that we can
52:49make to our dishes that make life easier
52:51for you and are more inclusive for those
52:52children with dietary restrictions then
52:54we're always willing to do that um we
52:56have another minute or so left so if
52:58anybody else has any questions please do
53:00turn your mic on or drop it into the
53:02chat um otherwise one more question I
53:05think oh is there one more yeah oh yeah
53:09sorry didn't see that one um okay so we
53:12often see a child with eczema also
53:15having a dairy allergy or parent
53:16believing it makes their skin flare up
53:19is there a proven scientific link
53:21between those two things so between the
53:23dairy and the exma flareups
53:26okay um the simple answer is yes um the
53:31longer answer is um eczema um is a um
53:38condition um and a disease if you like
53:41in itself that isn't caused by a food
53:45allergy um however um eczema can cause a
53:51food allergy so it's kind of the other
53:54way around so we know that children who
53:57have moderate to severe eczema so again
54:00let's clarify that we're not talking
54:02about children that come in with a
54:03little bit of of I'm not down
54:06downplaying it but a little bit of
54:07eczema on their skin folds um maybe you
54:10know on their arms on the back of their
54:12legs we're talking about little ones
54:14that come in that the minute you they
54:15come through the door you know they've
54:17got eczema you don't need to undress
54:18them to see they have eczema you know
54:20it's on the face you can see it on their
54:22hands and their arms so moderate severe
54:24eczema um we know that um those children
54:28are highly likely to develop a food
54:31allergy um in later life um however
54:35early that may be and that's why you may
54:37have all heard about early introduction
54:40of allergens to try and prevent that
54:41particularly in children with eczema so
54:44um if you've got eczema you're highly
54:46likely to develop a food allergy but
54:49food allergy does not cause eczema
54:53eczema is caused it's a genetic cause
54:55lot of a fagring gene and it's a a
55:00chronic condition um where there's
55:03dryness of the skin basically um however
55:07there there are lots of links because of
55:11um the way the immune system works that
55:16certain foods whether it be dairy or egg
55:19or whatever the parents report can flare
55:22the skin so it's really important that
55:26we we try and talk to the parents about
55:28treating that eczema flare um with all
55:30their emolient and you know these
55:32children often need to be have their
55:35creams applied four times a day um maybe
55:39using shortterm their steroid creams
55:42that their regimes and treating the
55:44eczema not cutting out loads and loads
55:47of different foods to try and cure the
55:50eczema because it's not going to cure
55:52the eczema cutting out Foods doesn't
55:55cure eczema it might stop shortterm
55:58flares but it's not going to cure the
56:01eczema I I hope that it's quite very
56:03very complicated but I hoping in a
56:05nutshell that does kind of answer your
56:09question great thank you penny I'm just
56:11going to squeeze in one more we've had a
56:13late entry if that's okay um hopefully
56:16more of a straightforward one for you
56:18should we allow parents with food
56:20intolerances to stop their child from
56:23trying that food and they've said this
56:25is from lady bird monor there's
56:28currently um is
56:30gluten okay I'm
56:33trying trying it
56:36so um so a child has a a parent has a
56:40food allergy and the mom doesn't want
56:42the child having that
56:43food that's what I'm
56:46assuming um I don't really know the
56:49answer I probably need a bit more detail
56:51about what the parental anxiety is
56:54really um
56:56with my dietitian hat on no we know that
57:00children that are avoiding foods are
57:02more likely to develop an allergy to
57:04them if they're not having them in their
57:05diet hence we talk about early
57:07introduction of food allergens again and
57:10why I like nurseries to include in their
57:13menus as many allergens as they can so
57:16the children that are there fulltime or
57:19for a lot of time during the week um
57:21excuse me again can um can get can get
57:25allergens in there
57:27their diet um so I I would want to know
57:31a little bit more but no I can't
57:33understand why a parent would want a
57:35child not to have um the allergen in the
57:38nursery setting because it's to me it's
57:41the ideal place to have it because the
57:43parent isn't having to prepare it or
57:45cook it or feed it the child yeah I
57:49think they've just come back and said
57:50yes both parents are glutenfree and they
57:52want their child to be as well because
57:54they think he will also be gluten
57:56[Music]
57:58intolerant um yeah that's I think that's
58:02something I don't think any PA can
58:04assume just because they are if they're
58:07talking about intolerant definitely not
58:09because we've talked about the
58:10definition of intolerance uh we don't
58:13inherit an in tolerance if they're
58:15talking about having celiac disease
58:17that's very different and it's really
58:20important the child has gluten in the
58:22diet so that um celiac disease can be
58:25diagnosed and we can't diagnose it if
58:27gluten isn't in the diet um but again
58:31you know we to a certain extent I guess
58:33we have to respect parental Choice don't
58:36we um and um it's not something that
58:40that I would necessarily recommend as a
58:42dietitian as an allergy dietitian I want
58:44every child um to have as many allergens
58:47as they can in the diet because it will
58:50reduce their likelihood of developing
58:52allergy now or in the future I think is
58:54the is the nutshell
58:57answer super that's brilliant thank you
59:00very much penny for joining us this
59:01evening for sharing all of your
59:03fantastic knowledge and thank you
59:04everybody else for for joining um and
59:07asking some fantastic questions um this
59:10session is recorded So if you've miss
59:12anything then you're very welcome to go
59:14back and watch the recording and we will
59:16also share the um fact sheets with you
59:20all as well again if you haven't already
59:22seen them um but that's it from us thank
59:25you so much penny it's been a pleasure
59:26to speak to you it's you're welcome I
59:29hope everybody's enjoyed it thanks thank
59:32you it's been brilliant thanks pedy by
59:34thanks everybody bye

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