Specialist Allergy Clinic Research Articles

Development and Validation of the Anaphylaxis Quality of Life Scale for Adults

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can have a detrimental impact on quality of life (QoL). There are no validated scales to measure the impact of anaphylaxis on QoL of adults. The aim of this study was to develop and assess the reliability and validity of a QoL scale for adults with anaphylaxis (Anaphylaxis Quality of Life Scale for Adults [A-QoL-Adults]). All participants were recruited from a specialist allergy clinic and had a confirmed diagnosis of anaphylaxis (as per the World Allergy Organization diagnostic criteria) to food, drugs, venom, or latex or had spontaneous anaphylaxis. Interviews were conducted with 13 adults; data were analyzed using thematic analysis to extract items for a QoL scale. A prototype QoL scale was then completed by 115 participants alongside validated scales to measure generic QoL (World Health Organization Quality of Life Scale [Brief Version] [WHOQoL BREF]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), and stress (Perceived Stress Scale [PSS]). The A-QoL-Adults scale has 21 items demonstrating excellent internal reliability (Cronbach α= 0.96). Factor analysis produced 3 subscales: Emotional Impact; Social Impact; and Limitations on Life. Each has excellent internal reliability (0.92, 0.92, and 0.91, respectively). Poorer anaphylaxis-related QoL (total A-QoL-Adults score and subscale scores) correlated significantly with poorer general QoL and greater anxiety, depression, and stress (all P < .01 with medium-to-large effect sizes). The A-QoL-Adults scale is a reliable measure of QoL in adults with anaphylaxis and shows good construct validity. It will offer health care professionals a means to further understand the impact of anaphylaxis on adult patients and could help direct and monitor allergy management and the need for further psychological intervention.

Diagnosis and Management of Allergic Rhinitis in Children

Allergic rhinitis which is the most common pediatric allergic disease has a significant negative impact on quality of life in affected children. Further, overall poor control can lead to ‘allergic march’ and later development of bronchial asthma. The main symptoms of allergic rhinitis include nasal discharge, blockage and itchiness of nose, and sneezing. Clinical history focused on identification of nature and severity of symptoms, trigger factors and clinical features of non-allergic rhinitis is crucial for early and accurate diagnosis.The mainstay of non-pharmacological management of allergic rhinitis is allergen avoidance.Second-line antihistamines used either locally or orally are first-line treatment of mild to moderate allergic rhinitis whereas topical nasal corticosteroids are the first line treatment for moderate to severe disease, in whom the control of symptoms is not achieved with antihistamine and those with severe nasal obstruction.Combination therapy with antihistamines and intranasal steroids is more effective than either alone and is second line treatment for children who have poorly controlled rhinitis while on monotherapy. Oral steroids may be indicated in children with significant nasal obstruction and routine use of oral steroids should be avoided.Referral to specialist allergy clinic should be considered for those who are symptomatic despite optimal local and oral therapy. Consideration should be given for specialist otorhinolaryngologist evaluation of children who have features of non-allergic rhinitis and pharmacotherapy resistant nasal obstruction.International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 Page: 159-162

Costs and uptake of a community model of paediatric food allergy care versus specialist hospital care: A before-and-after controlled trial.

To compare the costs of community-based food allergy model of care (intervention cohort, IC) with a tertiary-hospital, specialist allergy clinic model of care (control cohort, CC). In this pragmatic controlled trial, children (aged 0-12 years) newly referred to the allergy clinic at Melbourne's Royal Children's Hospital with suspected/known food allergy to three or fewer foods were allocated to see either a community-based paediatrician, trained via online webinars and web-based clinical decision support tools for food allergy diagnosis and management, or a hospital allergist. Per-patient costs to the health-care system and out-of-pocket costs to families seen within 12 months (clinician time, allergy tests and medicare billing) were compared between the two models of care. At 12 months, 54/181 (30%) CC families had been seen in the allergy clinic and 93/115 (81%) of the IC families who chose to see a community paediatrician had been seen. In an intention-to-treat analysis (ITT), health-care system costs per IC patient were higher than the costs per CC patient (mean cost $333 versus $319, respectively; mean difference $14, 95% Confidence Interval (CI) -97 to 118, P = 0.81). Total out-of-pocket costs to family were $129 in the IC compared with $89 in the CC (mean difference $40, 95% CI $4-$77, P = 0.03). A community-based model of care for simple food allergy showed that costs to the health-care system were similar between the community model and hospital care but did not show reduced out-of-pocket costs to the families 12-months post-enrolment.

Protocol for Pertussis Immunisation and Food Allergy (PIFA): a case–control study of the association between pertussis vaccination in infancy and the risk of IgE-mediated food allergy among Australian children

IntroductionAtopic diseases, including food allergy, have become a predominant cause of chronic illness among children in developed countries. In Australia, a rise in hospitalisations among infants coded as anaphylaxis to...

Shellfish/crustacean oral allergy syndrome among national service pre-enlistees in Singapore.

BackgroundAll Singaporean males undergo medical screening prior to compulsory military service. A history of possible food allergy may require referral to a specialist Allergy clinic to ensure that special dietary needs can be taken into account during field training and deployment.ObjectiveTo study the pattern of food allergy among pre-enlistees who were referred to a specialist allergy clinic to work up suspected food allergy.MethodsRetrospective study of all pre-enlistees registered in the Clinical Immunology/Allergy New Case Registry referred to the Allergy Clinic from 1 August 2015 to 31 May 2016 for suspected food allergy.ResultsOne hundred twenty pre-enlistees reporting food allergy symptoms other than rash alone were referred to the Allergy Clinic during the study period. Of these, 77 (64.2%) had food allergy. Among those with food allergy, mean age was 19.1 ± 1.5 years. They comprised predominantly Chinese (66.2%) and Malays (20.8%). The most commonly reported foods were shellfish/crustaceans (78%), peanut (15.6%), and egg (6.5%). Self-limiting oral allergy syndrome, OAS (itchy lips and throat with/without lip angioedema) was the most common manifestation (n = 33, 42.9%) followed by anaphylaxis (n = 23, 29.9%). Majority of OAS was from shellfish/crustacean (90.6%); of which shrimp (30.3%), crab (15.2%), and lobster (3.0%) were the most common. Mild childhood asthma (69.7%), allergic rhinitis (6.3%), and eczema (6.1%) were the most common atopic conditions among individuals with shellfish/crustacean OAS. This pattern was similar for shellfish/crustacean anaphylaxis. Skin prick tests were most commonly positive for shrimp (OAS 87.1% vs. anaphylaxis 100%), crab (OAS 95.8% vs. 90.9%), and lobster (OAS 91.7% vs. 63.6%).ConclusionOAS to shellfish/crustaceans was more common than anaphylaxis among this study population of young males referred for food allergy symptoms other than rash alone.

Chlorhexidine allergy in four specialist allergy centres in the United Kingdom, 2009-13: clinical features and diagnostic tests.

We describe an observational survey of diagnostic pathways in 104 patients attending four specialist allergy clinics in the United Kingdom following perioperative hypersensitivity reactions to chlorhexidine reactions. The majority were life-threatening. Men undergoing urological or cardiothoracic surgery predominated. Skin prick testing and specific immunoglobulin (sIg)E testing were the most common tests used for diagnosis. Fifty-three per cent of diagnoses were made on the basis of a single positive test. Where multiple tests were performed the sensitivity of intradermal, basophil activation and skin prick testing was 68% (50-86%), 50% (10-90%) and 35% (17-55%), respectively. Seven per cent were negative on screening tests initially, and 12 cases were only positive for a single test despite multiple testing. Intradermal tests appeared most sensitive in this context. Additional sensitization to other substances used perioperatively, particularly neuromuscular blocking agents (NMBA), was found in 28 patients, emphasizing the need to test for possible allergy to all drugs to which the patient was exposed even where chlorhexidine is positive.

Pollen food syndrome amongst children with seasonal allergic rhinitis attending allergy clinic.

There is limited information regarding the onset and sensitization patterns of pollen food syndrome (PFS) in children. The aim was to explore this within children referred to a specialist allergy clinic at a London Tertiary Hospital. A total of 54 patients with seasonal allergic rhinitis (SAR) were enrolled in equal numbers in three age groups; 0-5, 6-10, 11-15 years. Families completed a questionnaire on rhinitis, food symptoms and quality of life. Children underwent skin prick testing (SPT) to fresh fruits, nuts and a blood test for microarray analysis. Clinical diagnosis of PFS was made in 26/54 (48%), increasing with age (group 1 = 3 (17%), group 2 = 9 (50%), group 3 = 14 (78%) (p = 0.03)). Microarray demonstrates children aged 2.8 years sensitized to pan-allergens and 4.5 years symptomatic to pan-allergens. Peach, cherry, carrot and strawberry SPT had the highest sensitivity and NPV at 100%. The sensitivity of PR10 molecules on microarray was 92%, PPV 62% and NPV 87%. Microarray confirmed 69% of allergens on clinical history compared to 61% by SPT. Microarray and SPT had a 19% false-negative rate. The quality-of-life data showed moderate impact across all domains, and patients with PFS were significantly more likely to have increased anxiety over time spent preparing food (p = 0.029). We demonstrate that SAR occurs in children from 1.4 years and PFS from 4.5 years with a changing pattern of pan-allergen sensitization. Microarray and SPT have moderate concordance in confirming allergens. PFS impacts negatively on quality of life and should be assessed in all paediatric allergy patients.

What proportion of adult allergy referrals to secondary care could be dealt with in primary care by a GP with special interest?

BackgroundThe concept of a General Practitioner with Special Interest (GPwSI) was first proposed in the 2000 National Health Service Plan, as a way of providing specialised treatment closer to the patient’s home and reducing hospital waiting times. Given the patchy and inadequate provision of allergy services in the UK the introduction of GPwSIs might reduce the pressure on existing specialist services.ObjectivesThis study assessed what proportion of referrals to a specialist allergy clinic could be managed in a GPwSI allergy service with a predefined range of facilities and expertise (accurate diagnosis and management of allergy; skin prick testing; provision of advice on allergen avoidance; ability to assess suitability for desensitisation).Methods100 consecutive GP referrals to a hospital allergy clinic were reviewed to determine whether patients could be seen in a community-based clinic led by a general practitioner with special interest (GPwSI) allergy. The documentation relating to each referral was independently assessed by three allergy specialists. The referrals were judged initially on the referral letter alone and then re-assessed with the benefit of information summarised in the clinic letter, to determine whether appropriate triage decisions could be made prospectively. The proportion of referrals suitable for a GPwSI was calculated and their referral characteristics identified.Results29 % referrals were judged unanimously appropriate for management by a GPwSI and an additional 30 % by 2 of the 3 reviewers. 18 % referrals were unsuitable for a GPwSI service because of the complexity of the presenting problem, patient co-morbidity or the need for specialist knowledge or facilities.Conclusions and clinical relevanceAt least a quarter, and possibly half, of allergy referrals to our hospital-based service could be dealt with in a GPwSI clinic, thereby diversifying the patient pathway, allowing specialist services to focus on more complex cases and reducing the waiting time for first appointments.

Anaphylaxis to galacto-oligosaccharides--an evaluation in an atopic population in Singapore.

Anaphylaxis to galacto-oligosaccharides (GOS), a prebiotic, has been described in atopic patients following its supplementation in commercial milk formula in South-East Asia. The epidemiology of this usual allergy to a carbohydrate is unknown. This study evaluated the prevalence of allergy to two formulations of commercial GOS, Vivinal™ GOS (vGOS) and Oligomate™ , in an atopic cohort. Atopic subjects (n = 487) from two specialist allergy clinics were surveyed via structured questionnaire and underwent skin prick tests to GOS. Subjects with positive skin prick tests to GOS (n = 30, 6.2%) underwent basophil activation tests, and a subset (n = 13) underwent oral challenge tests to both formulations of GOS. Six subjects had positive challenges to vGOS; and none to Oligomate. By extrapolating the BAT and oral challenge results, the prevalence of allergy to vGOS is estimated at up to 3.5% (95% CI 2.2-5.5%) of our atopic population. Our findings show that GOS allergy may be common amongst atopics in Singapore.

Development and implementation of a decision pathway for general practitioners for the management or referral of suspected allergy.

Many patients with suspected allergy are referred to specialist care inappropriately. We aimed to develop and implement an online decision pathway to aid General Practitioners’ (GPs) management decisions in suspected allergy. Our study involved 1487 GPs, 3 referral management centres, 5 GP system suppliers, 4 primary care trusts, and 1 specialist allergy clinic. The pathway was implemented by 3/5 GP system suppliers, published to Map of Medicine and on a specialist clinic website. In the first year, the pathway ranked in the top 10/160 local care maps accessed via Map of Medicine and was viewed 900 times. Only 96 GPs registered to use the clinic website. Only 110 (7%) GPs responded to the feedback request, of which 13/110 (12%) had used the pathway; nearly all thought it useful. It was used by referral management centres as explanation of rejected referrals. Alternative approaches to embed its use are required.Significance for public healthOne in three people in the UK are affected by allergies during their lifetime. Early diagnosis and appropriate management can improve quality of life and reduce emergency hospitalisation. However, referring patients to secondary care is costly in terms of time and resources. We developed a pathway algorithm to support General Practitioners’ (GPs) allergy management and referral decisions to ensure that all referrals to specialist clinics were appropriate. The study illustrates a real world implementation with lessons for those seeking to improve the primary-secondary care interface, implementing pathways in various formats. In the UK, Map of Medicine seems to be the most used software. We demonstrated the difficulty of reaching GPs to encourage adoption of online decision support and suggest new ways forward by expanding care pathways into more detailed protocols for use directly by patients.

Patients' experience of a regional allergy service.

BackgroundThe principle reason for referral to specialist allergy clinics is to establish diagnoses and provide treatment plans to help patients manage their allergy. If patients do not accept, understand, or remember diagnoses or treatment, clinic visits may have been a waste of time. Few specialist allergy clinics follow up patients after diagnosis.Design and MethodsThis was a postal survey to assess patients’ i) perception of usefulness of specialist allergy clinic visits, ii) understanding of their allergy, iii) confidence in managing it, and iv) response to joining a regional online forum. Data for patients with confirmed allergy who attended the Peninsula Allergy Service (PAS) from 1998-2009 were extracted from consultant letters to general practitioners. Postal questionnaires were sent to 933 patients; 39% (336) responded.ResultsTwo-thirds (63%) thought their clinic visit useful and resulted in them being more in control of their allergy; 9% thought it useful but they still had problems, 26% thought it had not been much use. One in six (16%, 55) respondents had major differences in their view of their allergy compared to that recorded by PAS. Over half (56%) had had further symptoms since their clinic visit and 120 patients, who were not confident in coping with their allergy, listed aspects of their lives that gave concern.ConclusionsSpecialist clinics need routine feedback from patients if they are to monitor their effectiveness and some better form of follow up for patients is needed to reinforce education and support patients. Public education is important.Significance for public healthAlthough there is a great deal of information available about allergy on the Internet, in the media and via word of mouth from family and friends, unfortunately a fair proportion of this is misleading, inaccurate and even potentially dangerous. The main role of a specialist allergy service is the diagnosis and management of allergies and patient education during the consultation. This audit of patients diagnosed with type 1 allergy showed that a small but significant proportion may not have understood or accepted their diagnosis, others may not be confident in coping with their allergy, and over half had further symptoms after discharge from the clinic. The effectiveness of specialist allergy services will be diminished if there is no longer-term follow-up of patients. Public health education is also important so that patient expectations about the role of allergy services are realistic.

Validation of the Paediatric Food Allergy Quality of Life Questionnaire (PFA‐QL)

The Paediatric Food Allergy Quality of Life Questionnaire (PFA-QL) was the first tool to be developed for assessing health-related quality of life (QoL) in children with food allergy. It has been used in a number of published studies, but has not been validated. The aim of the current study was to validate child (PFA-QL) and parent-proxy (PFA-QL-PF) versions of the scale in a specialist allergy clinic and in parents of children with food allergy. For the clinic sample, a generic QoL scale (PedsQL) and the PFA-QL were completed by 103 children (age 6-16yrs) with peanut or tree nut allergy; test-retest reliability of the PFA-QL was tested in 50 stable patients. For the non-clinical sample, 756 parents of food allergic children completed the PFA-QL-PF, the Child Health Questionnaire (CHQ-PF50), Food Allergy Quality of Life Parental Burden Scale (FAQL-PB) and a Food Allergy Impact Measure. The PFA-QL and PFA-QL-PF had good internal consistency (α's of 0.77-0.82), and there was moderate-to-good agreement between the generic- and disease-specific questionnaires. The PFA-QL was stable over time in the clinic sample, and in both samples, girls were reported to have poorer QoL than boys. The PFA-QL and PFA-QL-PF are reliable and valid scales for use in both clinical and non-clinical populations. Unlike other available tools, they were developed and validated in the UK and thus provide a culture-specific choice for research, clinical trials and clinical practice in the UK. Validation in other countries is now needed.

Complexity of case mix in a regional allergy service

BackgroundCurrently in the United Kingdom (UK), there is a mismatch between limited financial resources and the large proportion of patients with suspected allergies actually being referred to specialist allergy clinics. To better understand the case mix of patients being referred, we audited referrals to a regional allergy service over an 8 year period.The main source of data was consultant letters to General Practitioners (GP) summarising the diagnosis of patients, archived from January 2002 to September 2009. Letters were reviewed, extracting the clinic date, doctor seen, gender, date of birth, postcode, GP, and diagnoses. Diagnoses were classified into seven groups and illustrative cases for each group noted.FindingsData from 2,028 new referrals with suspected allergy were analysed. The largest group of patients (43%) were diagnosed with a type I hypersensitivity. The other diagnostic groups were chronic idiopathic (spontaneous) urticaria (35%), suspected type I hypersensitivity but no allergen identified (8%), idiopathic (spontaneous) angioedema (8%), physical urticaria (2.5%), non-allergic symptoms (1.6%), type IV hypersensitivity (0.8%) and ACE inhibitor sensitivity (0.5%). Two thirds of patients seen were female with a higher percentage of female patients in the non type-I hypersensitivity group (71%) than the type 1 hypersensitivity (66%) (χ2 = 5.1, 1df, p = 0.024). The type 1 hypersensitivity patients were younger than other patients (38 Vs 46 years, t = -10.8, p < 0.001)ConclusionsThis study highlights the complexity of specialist allergy practice and the large proportion of patients referred with non-type I hypersensitivities, chronic idiopathic (spontaneous) urticaria being by far the largest group. Such information is critical to inform commissioning decisions, define referral pathways and in primary care education.

What factors affect the carriage of epinephrine auto‐injectors by teenagers?

BackgroundTeenagers with allergies are at particular risk of severe and fatal reactions, but epinephrine auto-injectors are not always carried as prescribed. We investigated barriers to carriage.MethodsPatients aged 12-18 years old under a specialist allergy clinic, who had previously been prescribed an auto-injector were invited to participate. Semi-structured interviews explored the factors that positively or negatively impacted on carriage.ResultsTwenty teenagers with food or venom allergies were interviewed. Only two patients had used their auto-injector in the community, although several had been treated for severe reactions in hospital. Most teenagers made complex risk assessments to determine whether to carry the auto-injector. Most but not all decisions were rational and were at least partially informed by knowledge. Factors affecting carriage included location, who else would be present, the attitudes of others and physical features of the auto-injector. Teenagers made frequent risk assessments when deciding whether to carry their auto-injectors, and generally wanted to remain safe. Their decisions were complex, multi-faceted and highly individualised.ConclusionsRather than aiming for 100% carriage of auto-injectors, which remains an ambitious ideal, personalised education packages should aim to empower teenagers to make and act upon informed risk assessments.

Parental perceptions and dietary adherence in children with seafood allergy

Allergy to seafood (fish, mollusc and crustacean) is increasing and is now a leading cause of food anaphylaxis, but there is only limited data on the impact of seafood allergy on affected children and their families. We assessed dietary adherence and perceptions of seafood allergy amongst the parents of 94 children presenting to a specialist allergy clinic with proven seafood allergy, by means of a postal questionnaire and cross-referencing the data obtained to clinical records. One-quarter of parents were unable to correctly recall the dietary advice provided. Nonetheless 89% of parents implemented a safe diet, but over half followed a more stringent elimination than that recommended. One-fifth of the children had subsequent allergic reactions to seafood after diagnosis, and these were generally a result of accidental rather than intentional exposure or cross-contamination. Provision of an adrenaline auto-injector device was associated with increased adherence to dietary advice. Oral food challenges had a beneficial effect on parental perceptions and were helpful to parents in managing their child's allergy. Seafood allergy has a significant adverse effect on anxiety and stress in the families of affected children. Parental recall of dietary advice is variable and many tend to impose more stringent dietary avoidance than that recommended. Despite this, subsequent accidental reactions are common. Thus, the avoidance of seafood in children may be more difficult than often presumed.

When doctors disagree: a qualitative study of doctors’ and parents’ views on the risks of childhood food allergy

To examine the views of doctors which underpin clinical practice variation concerning an uncertain health risk, and the views of parents who had sought advice from these doctors, using the example of childhood food allergy. Qualitative study involving in-depth interviews and participant observation over 16 months. Focus groups and consultation audio-recordings provided corroborative data. Three specialist allergy clinics located in one metropolitan area. Eighteen medical specialists and trainees in allergy, and 85 parents (from 69 families) with food allergic children. Doctors expressed a spectrum of views. The most divergent views were characterized by: scientific scepticism rather than precaution in response to uncertainty; emphasis on quantifiable physical evidence rather than parental histories; professional roles as providers of physical diagnosis and treatment rather than of information and advocacy; libertarian rather than communitarian perspectives on responsibility for risk; and values about allergy as a disease and normal childhood. Parents held a similar, but less divergent range of views. The majority of parents preferred more moderate doctors' views, with 43% (30 of 69) of families expressing their dissatisfaction by seeking another specialist opinion. Many were confused by variation in doctors' opinions, preferring relationships with doctors that recognized their concerns, addressed their information needs, and confirmed that they were managing their child's allergy appropriately. In uncertain clinical situations, parents do not expect absolute certainty from doctors; inflexible certainty may not allow parental preferences to be acknowledged or accommodated, and is associated with the seeking of second opinions.

Allergen immunotherapy in children

Specific allergen immunotherapy is the only potentially curative allergy treatment currently available. It is used in Europe and North America in the treatment of allergic rhinitis, venom allergy and asthma in children. However, following a series of deaths in the 1980s, the use of immunotherapy in the UK is limited to a small number of specialist allergy clinics. This article reviews the route of administration, safety, efficacy and indications for specific allergen immunotherapy in children. New developments in immunotherapy are discussed.

Attributes and views of families with food allergic children recruited from allergy clinics and from a consumer organization

A significant body of food allergy research has been conducted with families recruited from consumer organizations (COs). However, there has been no systematic comparison of the characteristics of such families with those attending specialist allergy clinics (ACs), nor have parental views on food allergy COs been examined in detail. To address these questions, 44 families with food allergic children recruited from hospital clinics and 25 families recruited from a CO: (i) completed a survey with items concerning demographic details, allergy features, and sources of allergy information, and (ii) participated in qualitative interviews and focus groups concerning their experiences. Significant differences were found in reported number of food allergies and nut allergy, seeking of second opinions, adrenaline autoinjector possession (but not use) and sources of food allergy information. Parents valued COs as sources of practical information and emotional support, but viewed advice which did not acknowledge their individual circumstances and heightened anxiety from contact with other anxious parents as being unhelpful. Research conducted with CO members is valuable, but may have limited generalizability to other populations. To supplement the information and support provided by ACs, all parents should be given the opportunity to join a CO, with guidance from their clinician towards those aspects of membership which are most likely to be helpful.

Prescription of adrenaline auto-injectors for potential anaphylaxis—a population survey

Objective. To assess the quality of training provided to parents of children prescribed adrenaline auto-injector devices, adherence to the Chief Medical Officer's recommendation regarding specialist referral, and effect of allergies on quality of life. Setting. Middlesbrough, Redcar and Cleveland districts in North-east England. Design. Postal questionnaire to parents of all children prescribed an auto-injector in the area ( n=154). Results. One hundred and seven parents replied. General practitioners were the source of initial prescription for 30 children. Fifty-one children were not referred to a specialist allergy clinic. Four parents said that they had received no training in the use of the device. Dummy auto-injectors were not used to train 51 parents. Forty-six families were not given the opportunity to retrain. Eleven parents had low or very low confidence in the use of the device, and 13 parents were unsure when to use it. Quality of life was significantly affected. Sixteen children were bullied as a result of their allergy. Thirty parents felt that their child could not do something they really enjoyed as a result of the allergy, and 39 parents felt that their own lifestyle was affected. Conclusion. The impact of the prescription of auto-injector devices should not be underestimated. National guidelines regarding specialist referral were often not followed, and this needs to be addressed by primary care organizations. Quality of training issues needed to be addressed and this has led to re-organization of services in our district.

The prevention and management of anaphylaxis in children

The severity of allergic reactions covers a spectrum, from mild (e.g. facial urticaria) to severe (severe dyspnoea and/or hypotension). Anaphylaxis represents an extreme end of this spectrum and has unpredictable and life-threatening consequences. In the adult population it is most often caused by drugs, food and hymenoptera venom, but in young children food and drugs are usually responsible. The incidence has increased over recent years, a trend seen in all allergic disease. Treatment of acute anaphylaxis is described. Prevention of further episodes is vital and is most effectively achieved by early referral to a specialist allergy clinic. The cause of anaphylaxis may then be determined, detailed advice given on allergen avoidance and treatment of further reactions, with training of carer/school in allergen avoidance and self-administration of emergency medication. This approach has been shown to reduce the number and severity of subsequent allergic reactions and provides a model of good practice applicable to all causes of anaphylaxis.