The following pre-referral guideline covers recommended pre-referral management and investigations for children of all ages with a suspected food allergy.
The most common foods causing allergies in children are egg, cow's milk, peanuts, tree nuts (e.g.cashews), wheat, soy, fish, shellfish and sesame. Reactions to many other foods do occur, but are less common
Food allergy (caused by an immune mechanism) is different to food intolerance (not caused by an immune mechanism). Examples of intolerance include lactose intolerance due to absence of lactase enzyme in GI tract, monosodium glutamate, skin reactions from strawberries, citrus or tomatoes.
Most food allergies are not life-threatening.
When to refer
- Previous confirmed or suspected anaphylaxis - Always. This is an URGENT priority REFERRAL ( at time of acute reaction refer to Emergency Department)
- Suspected food allergy with failure to thrive-Priority referral.
- Multiple food allergies or suspected non-IgE mediated food allergy.
- Other significant co-existant allergic disease (eg child with significant eczema and food allergy, or troublesome asthma and food allergy)
- Dysphagia
- Reflux/ GI symptoms.
- History and blood test IgE levels/ Skin Prick Test do not correspond (eg + Hx but -ve test) as further specialised testing (ie. challenge) may be needed.
- Please also see under 'Interpretation of blood IgE tests below
Taking a history
History of allergic reaction -
- Food - food type, amount, form ingested in (cooked or raw), time to reaction.
- Has the food been taken without reaction in the past? Has it been taken since?
- Specific details of nature of reaction.
Detection of allergen specific IgE
- Allergen-specific IgE detection in a blood tests is recommended
- Specific allergen of interest will usually be indicated by history.
- Only perform a blood IgE test for food allergy if suspect an IgE mediated allergy (not useful for non IgE mediated).
- Skin Prick Tests should only be performed by those with appropriate training as there is a small chance of a systemic reaction.
Interpretation of allergen specific IgE test/ Skin Prick Test
- Blood IgE tests should be performed to investigate a +ve history of reaction to a food,and should be limited to the antigen (Ag) of specific interest. as indicated from the history.
- Blood IgE tests to foods that a patient has already eaten and tolerated OR that the patient has not yet been exposed to is not recommended.
- Detection of allergen specific IgE by blood test/ skin prick test does NOT necessarily indicate clinical allergy. Test results must be interpreted together with history.
- Positive allergen-specific IgE AND clear history of allergic reaction confirms clinical allergy.
- Recommend strict avoidance of specified allergen, provide education on management of allergic reactions and supply 'action plan'.
- Refer to an Allergy Specialist if anaphylaxis or multiple food allergies or other significant co-existing allergic disease (eg significant eczema and food allergy).
- Allergy to a single food, refer to an Allergy Specialist or to a Paediatrician with a special interest in allergy.
- Negative blood IgE and positive history of reaction may indicate non-IgE mediated allergy.
- Refer to Allergy Specialist for further management and instruct patient to avoid the specified allergen.
- If a food has been eaten without reaction, IgE blood test is not required as allergy excluded (i.e. performing a blood IgE test in setting of no history is discouraged).
- If blood IgE and history do not correspond refer for further evaluation.
Prereferral management of anaphylaxis
- Prescribe Epi-Pen/ Epi-Pen junior.
- To access authority funding for an epi-pen, discuss with an allergist, paediatrician or ED Consultant (by phone via RCH switchboard).
- Educate on correct use of Epi-Pen.
- Provide Anaphylaxis Action Plan
(health professional anaphlaxis resources)
- Ensure any asthma is well controlled.
- Educate on strict avoidance of allergen.
- Support parent in school/ day care communication.
- Do not attempt to perform a challenge to the allergen. This should only be done in a specialist allergy unit.
Prereferral management of Mild-moderate reactions (including contact reactions)
- Antihistimine will alleviate symptoms of hives and itches but will not treat anaphylaxis.
- Loratidine (Claratyne) and certirizine (Zyrtec) are suitable for children under 2 years of age and are available in syrup form.
- Ensure any asthma is well controlled.
- Educate on strict avoidance of allergen.
- Support parent in school/ day care communication.
- Do not attempt to perform a challenge to the allergen. This should only be done in a specialist allergy unit.
- Provide an
ASCIA Allergic reaction action plan.
Other management
- Emphasise that the majority of food allergies are not dangerous.
- Avoidance of allergenic foods as a means of preventing the development of food allergy is not recommended if the child has never been exposed or never had a reaction to the food. Parents should introduce small amounts of food and observe.
Do not refer
- For allergy screening if there is no clear history of allergic reaction - such referrals will be rejected.
- Family history of allergy, in a healthy patient who does not have an allergic condition.
Referral information needed
The GP at first consultation is in the best position to get the most comprehensive information from parents on the details of an allergic reaction. Please collect and include in your referral as much detail as possible. It is increasingly difficult to collect this information later.
Information needed:
- CLEARLY INDICATE if child has confirmed or suspected ANAPHYLAXIS. The referral will be triaged as urgent.
- Date reaction(s) occurred.
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Allergic reaction symptoms experienced -
- Severe systemic reaction (anaphylaxis).
- Difficulty breathing.
- Swelling of the tongue or throat.
- Difficulty talking.
- Hoarse voice, wheezing or persistent coughing.
- Loss of consciousness and/or collapse.
- Young children appearing pale and floppy.
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Moderate systemic reaction -
- Abdominal pain, vomiting.
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Mild-Moderate local reaction -
- Swelling of lips, face or eyes.
- Hives or welts.
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Potential causes of reaction(s):
- When, where and how did the reaction(s) happen?
- blood IgE results.
- Treatment given and patient response.
- Previous or subsequent exposure to allergen.
- Please send blood IgE or other results together with your referral.
Contact information
Clinical advice
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Clinical advice Page the 'on-call' Consultant or Allergy and Immunology Fellow.
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(03) 9345 5522
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RCH Emergency Department:
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(03) 9345 6477
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Resources, references and further information
Related pre-referral guidelines
Copyright and Disclaimer
Copyright 2009, Royal Children's Hospital (RCH) Victoria, Australia. The RCH is not responsible in any way for application of the procedures or guidelines to patient care at your facility. They are guidelines only and your professional judgment must always prevail. Guidelines may not be reproduced without permission. RCH Kids Connect - Primary Care Liaison.
www.rch.org.au/kidsconnect
. These guidelines were developed by specialists at the Royal Children's Hospital and reviewed by general practitioners in Victoria. Last reviewed October 2013.