Australian children have one of the highest rates of food allergies in the world, writes Leanne Philpott

Yet a recent survey uncovered a serious need for extensive community education on allergies—a role that pharmacy is well placed to perform.

In Australia, as many as 10% of 12-month-old infants have a clinically confirmed food allergy. Vicki McWilliam, dietician in the Allergy and Immunology Department at The Royal Children’s Hospital Melbourne, explains, “Cow’s milk allergy is the most common allergen we see in young babies. It’s often a transient allergy, and for many babies resolves by 12 months of age.

“However, the most widespread condition we see misdiagnosed is lactose intolerance and cow’s milk protein allergy.”

She explains that pure lactose intolerance is very rare in babies. The more common cause of lactose intolerance in infants and young children is a bout of gastroenteritis – resulting in secondary lactase deficiency.

Having pharmacists explain the difference between lactose intolerance and cow’s milk allergy can be helpful, particularly for parents with an undiagnosed infant or child.

To add to parent’s confusion, cow’s milk allergy and lactose intolerance can share some of the same symptoms:

  • Diarrhoea
  • Abdominal pain and/or bloating
  • Vomiting
  • Irritability

What might distinguish cow’s milk allergy is the addition of allergy symptoms such as urticaria, erythema, angiodema, wheezing, breathing difficulties or runny nose.

McWilliam says that a key role for pharmacy is in helping parents to make an informed choice when it comes to infant formula.

“There are formulas on the market that don’t contain lactose but still have cow’s milk protein in them. If it’s cow’s milk protein allergy that the child has, lactose-free formula isn’t right for them. This is often where the mistake is made.

“Even if a parent comes in to pick up a particular formula on the advice of a GP, it’s worth double checking why they have selected this type of formula to ensure it’s the correct formula.”

 

Infant formula advice

Late last year Bayer introduced Novalac Allergy onto the market—a rice-based formula for children with cow’s milk protein allergy. At the time of launch professor Pete Smith, medical director of Allergy Medical in Sydney and Brisbane, said the new formula was positive news for parents of infants with the condition, as there is a significant proportion of cow’s milk allergy sufferers who still react to hydrolysed formulas or are unable to tolerate amino acid formulas.

“The mainstay of treatment is to remove the allergic cow’s milk protein from the child’s diet while ensuring alternative feeding options are nutritionally adequate. With the availability of Novalac Allergy, parents now have access to a non-soy and non-dairy nutritionally complete formula which helps achieve an optimal weight by six months and is tolerated by over 90% of babies with a demonstrated cow’s milk protein allergy,” he said.

Whereas soy formulas used to be the only option for infants and children with cow’s milk allergy, nowadays extensively hydrolysed formulas (EHFs) and amino-acid-based formulas (AAFs) are considered more appropriate and are available on the PBS.

Australia and New Zealand dietary guidelines recommend against soy products for infants under the age of six months so in this case Novalac Allergy is an appropriate option, along with Allerpro, an EHF formula available OTC.

For infants older than six months, soy-based formulas such as Karicare Soy or S26 Gold Soy might be recommended.

While pharmacy staff are often called upon for advice on infant formulas for babies and children with a suspected food allergy, McWillam says the overarching message for pharmacy is to urge parents or carers to seek an accurate diagnosis from their GP.

“Particularly when parents are cycling through, trying all the different formulas to find one that might make their baby a bit more settled—that’s when you can run into problems. Especially as they’ve probably been given differing pieces of advice from friends and family,” she says.

 

New allergy prevention guidelines

The other area of allergies where pharmacy can play an important role is in educating parents on the latest guidelines for the introduction of allergenic foods.

McWilliam says, “We now have good level evidence for the introduction of egg before 12 months and high-level evidence of the introduction of peanut before 12 months as a preventative action against the development of allergies. 

“The key is to introduce these foods before 12 months of age, even in children who are at high risk of allergies. For example, if you have eczema—and even if you have an egg allergy—we still recommend introducing peanut before 12 months.”

Key advice points from the Australasian Society of Clinical Immunology and Allergy (ASCIA) include:

  • Introducing solids – including those which may cause allergy, around six months – but not before four months of age
  • Include cow’s milk, egg, peanut, tree nuts, soy, sesame, wheat, fish and other seafood.
  • Once introduced, continue to regularly include these foods in your baby’s diet.
  • Introduce cooked egg and peanut during daytime so that you can watch your baby and easily respond if they have an allergic reaction.
  • Introduce well-cooked egg and smooth peanut butter/paste in small amounts to start with and gradually increase the amount as long as there are no signs of allergic reaction.

McWilliam points out that while introducing highly allergic foods as a preventative measure is important, parents should not consider it an emergency.

“You don’t need to feed your baby these particular foods as soon as they start eating solids, but according to the study the optimal window of time is within the first 12 months.

“The average age of introduction for peanut was around seven months, for example. This allows you to introduce a few foods, which you can then mix egg or peanut into.”

Alongside advising parents on these new prevention guidelines, McWilliam says pharmacists can also help dispel a popular misconception.

“We definitely don’t recommend rubbing food on the baby’s skin, especially if they have eczema. Instead, parents can rub a small amount of the food inside the baby’s lip as a starting point. If there’s no allergic reaction after a few minutes, they can start giving small amounts of the food.”

“There’s research that suggests if you are exposed to the food proteins via your skin, before you’ve built up oral tolerance, it can increase the risk of developing a food allergy. So young babies that have really bad eczema and a damaged skin barrier absorb the protein through their skin and that seems to be an early way that the immune system induces intolerance to those proteins.

“As such, pharmacy staff can promote early prevention of eczema by advising on appropriate moisturisng and bathing practices in babies to make sure we’re protecting that skin barrier.

“Alongside the timely introduction of peanut and egg, that’s really the only protective message we can offer parents at the moment.”

 

Ignorance feeds allergy

A recent Galaxy Research Poll, commissioned by Allergy and Anaphylaxis Australia, has revealed a serious need for widespread community education on allergies.

Responses from 1000 Australian adults showed that:

  • 69% would not know how to help someone with anaphylaxis,
  • 70% did not know how to use an EpiPen and nearly 31% didn’t know what an adrenaline autoinjector was,
  • 56% thought people with a food allergy were “over cautious” about what they ate and 27% went as far as to say that there was “a lot of fuss” about food allergy and we had become “over-protective”.
  • Only 4% knew that you could be allergic to any food and 49% did not know that you could develop an allergy to a food that you have eaten before without a reaction.

“The research reveals an extremely dangerous combination of lack of awareness and complacency. Australians need to recognise people with food allergies are not making a ‘fuss’ and that this is a medical issue we need to all take seriously,” says Maria Said, Allergy & Anaphylaxis Australia CEO.

“Australia has one of the highest rates of food allergies in the developed world and it is increasing at a frightening rate. One in ten babies born today will develop a food allergy.

“To have any chance of preventing food allergic reactions, including fatalities, we need to significantly increase community awareness so that those with food allergy can work toward avoidance and everyone can spot the signs of anaphylaxis and know what to do in an emergency. We all need to be allergy aware; how to use an adrenaline auto-injector must become common first aid knowledge, just like CPR.”

According to Allergy and Anaphylaxis Australia, the signs of a severe allergic reaction can include:

  • Dizziness
  • Collapse
  • Pale and floppy (young children)
  • Swelling of the tongue
  • Difficulty talking and/or hoarse voice
  • Difficult breathing/noisy breathing
  • Wheeze or persistent cough
  • Swelling or tightness in the throat

In the case of anaphylaxis, the following action should be taken:

  1. Lay person flat and raise their legs if possible (if breathing is difficult allow to sit)
  2. Administer the adrenaline autoinjector (EpiPen)
  3. Call an ambulance
  4. Call their emergency contact
  5. After 5 minutes, if there is no response or their condition worsens, administer a second adrenaline autoinjector (if available)

Recently there were changes made to the way an EpiPen is used. The changes include:

  • Reduced injection hold time from 10 to 3 seconds
  • No need to massage the injection site
  • Existing 10-second labeled EpiPens don’t need to be replaced, they can simply be held for 3 seconds instead.

Being up to date on the latest allergy information and advice is important for pharmacists, but it’s also vital that pharmacists advise anyone presenting with a suspected food allergy to get the right diagnosis.

Dr Suzan Bekir, clinical director at The Australian Allergy Centre, says, “Encourage patients to be reviewed by an allergy-trained doctor or specialist who will normally use a clinical history supported by skin prick allergy tests or allergy blood tests to help confirm or exclude potential allergies.

“Self diagnosis should be avoided; long-term unsupervised restricted diets should not be undertaken, as this can lead to malnutrition and other complications such as food aversion.”

 

Addressing hives

Despite the many factors associated with allergies, the focus of this year’s World Allergy Week was ‘The agony of hives’. Dr Bekir explains, “Hives cause many patients hours of physical discomfort. They itch, burn, sting and can significantly impact quality of life.

“Some patients even describe being socially embarrassed and fearing going out, as hives can appear in places they least want such as their face and neck. Chronic hives has been associated with a higher rate of anxiety and depression.”

Part of the message of World Allergy Week surrounded the fact that while food allergy is a potential cause of hives, it’s not the most common cause.

“It’s a common misbelief that hives must be caused by an allergy. Food allergy most definitely can cause hives, yet not all hives are caused by allergy!

“In children the most common cause of hives is in fact viral infections. Other common causes include allergic reactions to medications and this is where I believe pharmacists have an important role to play,” says Dr Bekir.

“For adults, particularly with chronic hives, a medication history is extremely helpful. Pharmacist could help patient’s identify which of their medications (prescription or non-prescription) could be causing their hives.

“Common medications like antihypertensive, NSAIDS and the combined oral contraceptive pill (COCP) can cause hives and may be overlooked by the patient because their hives started after they’ve been on their medication for some time.”

She says that in 80% of cases a cause may not be found. Suggesting a review with an allergy-trained-GP, allergist or immunologist is certainly the best method for identifying the cause of hives.

“Antihistamines can be effective in treating acute hives, but explaining common aggravating factors can also help patient’s enormously.

“Stress can be a trigger but avoiding hot showers or excessive heat, tight clothing, alcohol and hot spicy foods can be useful too. Aspirin should be avoided, as it can often make symptoms worse. 

“Alongside the use of antihistamines, pharmacists can suggest the use of cool packs or cooling gels with aloe vera. Steroid creams rubbed over the hives may also help ease the discomfort,” says Dr Bekir.