Frequently Asked Questions

Eczema is very common in babies. If it occurs before the age of 6 months, it is often associated with food allergy. If it starts after the age of 6 months it can be due to food allergy but may also be due to food chemical intolerance. My usual advice is that if the eczema is very hard to treat, the mother should minimize the amount of dairy products she consumes and she should consult the family GP for more specific advice. In many cases, soy products are a good substitute in the mother’s diet. If the mother does not take soy, she needs calcium supplementation in her diet. Two Caltrate tablets a day should be sufficient. The mother should also decrease the amount of tomato and citrus she is taking, and cut back on dried fruit, stone fruit, melons and berries. These can all worsen eczema in a breast fed baby. The mother will need to eat something else to replace these foods, and increasing the amount of meat, and bland carbohydrates, such as rice and potato, would be one way to do this. It would be appropriate to consult a Dietitian if the mother wants to change her diet in this way. If the baby is bottle fed, consider changing from a milk-based formula to a soy-based formula, except if the baby is less than 6 months old. It is worth noting here that if a baby is less than 6 months old, and reacts to milk based formula, that baby will likely also react to soy, so changing formula should be done with the help of a Paediatrician. If the child is taking solids, the amount of tomato, citrus, dried fruit, stone fruit, melons and berries should be decreased. Other foods will need to be substituted, such as bland cereals and meat. Again, seeing a Dietitian would be wise. In all children with eczema, I recommend decreasing the child’s contact with house dust mite, by decreasing the contact with carpet, and the use of good quality dust mite covers for bedding on all beds the child gets into. I recommend avoidance of soap, and frequent use of good quality skin moisturizer. Steroid creams and ointments are very safe and useful treatments for eczema. They have been used for many decades and do not cause any serious side effects when used appropriately. Cream should be used twice a day until the rash has completely settled. The amount of cream to use is 2cm of cream to cover the area of 2 adult palms. It is better to continue treatment until the rash is gone, rather than stopping early and having the rash come back over and over; less cream overall is used by treating adequately the first time rather than half treating many times. The use of a sedating antihistamine is often useful as this allows the child to sleep well and not scratch, and lets the skin heal and regain its normal barrier function. Sedating antihistamines should be used for short periods only, and if the child is less than 2 years old, medical advice should be sought before using these medications.

I also recommend stopping the use of all hand and nappy wipes (for all skin other than the nappy area) and all hand sanitisers on both the parents and the child, as these all take the oil out of the skin and make it more open to irritation from the environment. If the parents use hand sanitisers before applying the child’s skin creams, some of the hand sanitiser will be transferred to the child’s skin.

No. The size of the skin prick test is recorded so the doctor can have complete records of any testing undertaken. Many studies have looked at this issue, and all have shown that there is absolutely no link between the size of the skin reaction and the severity of the reaction a person would have if they eat that food. Roughly speaking, the bigger the skin prick test result, the bigger the reaction that would happen. It is not possible to compare the severity of an allergy between one food and another on the basis of the size of the skin prick test. Nuts are much stronger at provoking allergic reactions than other foods and comparing the size of a nut skin reaction to that of egg, for example, cannot show which allergy is worse.

Skin prick testing can safely be done at any age, but is more reliable when performed after age 6 months. Even at that time, there can be false negative results, meaning that there could be a real allergy, but the skin prick showed no reaction. Generally, all skin prick tests for foods should be reliable by age 12 months.

No. A positive skin prick test only means that the body has formed IgE antibodies against that substance. It does not necessarily mean that this will trigger an allergic reaction. Diagnosis of allergy means that the person should have had a reaction to exposure to that food or other substance, and has a positive skin prick test, or positive blood test (capRAST test) for that substance.

Sometimes it is useful to confirm that there is a real allergy to a particular food, by doing a food challenge under medical supervision.  This link has useful information about food challenges: https://www.allergy.org.au/images/pcc/ASCIA_PCC_Food_allergen_challenges_FAQs_2019.pdf

No. Skin prick testing is more accurate than blood testing. Both can be useful in the management of a person; I generally would use blood testing in a person who was not able to have skin prick testing, perhaps due to severe skin rash at the time I would want to do the skin testing in the office, or if the person lived a great distance from specialist medical care. I usually reserve blood testing for situations where I feel the person is likely to be outgrowing his allergy, and I am considering supervised oral challenging with that food. The results of blood testing do not correlate with the kind of reaction a person would have if they ate that food; researchers have analysed the results of large numbers of oral challenges compared to blood and skin prick test results, and have drawn up charts showing the likelihood of a reaction of some sort, compared to blood test results, but were totally unable to predict the severity of a reaction.

I generally do not perform oral challenges to confirm a diagnosis of allergy, as most children have already reacted to the food before coming for an appointment.

I may suggest food challenges to confirm a diagnosis if there is any doubt, and also if it appears that the person may be outgrowing the food allergy.

Food challenges are not a treatment to make a person outgrow an allergy.

No. There is evidence that children who are breast-fed can become allergic to foods that the mother eats, as small amounts of many foods are found in breast milk. This does not mean that mothers should or should not breast feed their babies.

Good information on the prevention of allergies in babies can be found at

https://preventallergies.org.au

Investigation and treatment of allergic disorders is best done with scientifically proven methods such as Skin Prick Testing and cap RAST testing, both of which detect the presence of IgE antibodies specific to certain foods or other allergens.

IgG testing for foods is not scientifically valid, and should not be part of the diagnosis of any food allergy. Scientists investigating how to induce tolerance to allergens (“desensitising” a person against a food to which they are allergic) measure the presence of IgG antibodies to foods. The presence of IgG antibodies tends to indicate protection against having an allergic reaction.

Food intolerance can only be investigated and treated with dietary exclusions and challenges.

A full explanation of this can be found at 

https://www.allergy.org.au/hp/papers/unorthodox-techniques-for-diagnosis-and-treatment

There is no single answer for this. In any individual there are many factors, which contribute to the development of allergy, including a genetic predisposition (family history), and exposure to the substance in question. Many theories are being put forward including “the hygiene hypothesis”, which says that people are not getting sick with infectious illnesses so frequently and therefore are immune systems attack food instead of germs. I think the western diet we eat has a part to play, as we are eating more processed foods.

There is a lot of research being conducted at present about the role of various germs in our intestines and the way they influence our tolerance or allergy to foods.

The latest information on prevention of allergies, and on the development of allergies can be found at https://preventallergies.org.au

Eczema is not in itself caused by food but can be made worse by it. If a child has eczema, there is a much higher chance than average that the child will have allergy to egg, and possibly to peanut, so I generally suggest the child with hard to control eczema should be investigated for these allergies. Children where the eczema is easily controlled with occasional use of topical steroid creams do not need this testing.

If there has been a reaction to a food then that food should be avoided until testing is done and discussion of the results is completed. The parents need to talk to a properly qualified Allergist and Dietitian for further advice.

https://www.allergy.org.au/images/pcc/ff/ASCIA_Eczema_Fast_Facts_2019.pdf

I suggest that if a medicine is not strictly necessary, it is better not to take it. If the child does need medication, for example pain relief or antibiotics, then the child can be given the appropriate dose using an adult capsule (broken open) or tablet (crushed up). If this is done then the parent can mix the medication with soft food and give it to the child. It is best not to mix it in the baby’s milk/ formula or juice, as the complete dose may not be taken or the fluid in which it is placed may inactivate the medication. If the parents are keen then medications can often be made up into syrups without colour, flavour or preservative. A Compounding Pharmacist does this. You will need to talk to your local Pharmacy about where to access your closest Compounding Pharmacy.

Yes. The use of the MMR vaccine and Influenza vaccines has been shown to be very safe for egg allergic children. Useful information can be found at https://www.allergy.org.au/images/pcc/ASCIA_PCC_Egg_Allergy_and_Influenza_Vaccination_2019.pdf and https://www.allergy.org.au/images/stories/pospapers/ASCIA_Guidelines_vaccination_egg_allergic_individual_2017.pdf

It is possible to eat out at restaurants, providing you carefully explain to the staff about the allergy and choose carefully from the menu. I usually advise that you go to a restaurant with which you are familiar and where you feel you can communicate well with the staff. If in doubt, leave the restaurant without ordering. I also suggest that when the food arrives at the table, the allergic person touches the food to the tongue and then waits for a few minutes (you may need to have a distraction for the hungry child, such as colouring in or something else to eat); if there is no tingling in the mouth or swelling of the lips in a couple of minutes after touching the food to the tongue, then it is likely to be safe to eat that food.

https://allergyfacts.org.au/component/search/?searchword=Eating%20out&searchphrase=all&Itemid=101 

This is a controversial question. The answer depends on the degree of risk a person is willing to take. In my experience, chocolate is the most likely food to cause reactions due to hidden traces of nuts. This also includes chocolate as an ingredient of foods (chocolate chips, and chocolate coated biscuits). My advice is that if a nut allergic person wants to eat chocolate then the person should consider choosing a nut free chocolate product. There are plenty of these available. The other foods likely to cause reactions due to hidden traces of nuts are muesli bars or muesli cereal. The more highly processed a food is, the more likely the chance that nut traces will be found contaminating the food.

In general there is no need to avoid eating foods labelled as possibly contain traces of allergens.

A person cannot be allergic to something they have never been exposed to. This means that a person will not be allergic to foods they have never eaten (but in the case of babies, they are exposed to foods through breast milk).

Many children with eczema become allergic to traces of foods in the home environment. If the child has broken skin, it is important to treat this properly, so that peanut, in particular, does not get absorbed through the broken skin.

If the eczema is hard to control, I suggest the child does not eat egg or nuts for the first time, before getting skin prick tests performed; the results should be discussed with an Allergist as they can be difficult to interpret, and not all positive results mean there is true allergy.

Good information can be found at  https://preventallergies.org.au

And https://www.allergy.org.au/images/pcc/ff/ASCIA_Eczema_Fast_Facts_2019.pdf

If an allergic child refuses to eat something, he or she should never be forced to eat that food. One of the first symptoms of an allergic reaction is a tingling or itchy feeling in the mouth, which is so unpleasant the child usually spits the food out and starts to rub at the mouth. Making a child eat something they are unhappy to eat may be forcing them to have a bigger allergic reaction. I recommend that if a child refuses to eat something, the child should be watched carefully for the next hour or so as they could go on to have an allergic reaction. The caregiver should make the medications on the Allergy Action Plan available to use if the child does go on to have a reaction.

This question does not necessarily have a clear answer, which would apply to everyone. The foods most likely to cause a severe allergic reaction are nuts. Largely speaking, children with asthma are at slightly higher risk of having a severe allergic reaction, requiring the use of an Epipen, in comparison to children without asthma. Other factors to take into consideration are whether the child has had a previous severe allergic reaction, if the child is allergic to many foods as well as nuts, and if the nut allergic child is also allergic to dust mite.

Information can also be found at https://www.allergy.org.au/images/stories/anaphylaxis/2016/ASCIA_Guidelines_AAI_Prescription_2019.pdf

It is very common for babies to be unsettled. There are many different reasons that a baby could be irritable. Some babies have reflux, meaning they have heartburn type discomfort, and some babies have difficulties settling into routine, or are over stimulated. I suspect food may be an issue if the baby has a rash on the face or on the bottom after eating certain “acidy” foods (either the breast feeding mother or baby eating these). These foods include tomato, citrus, berries, stone fruit, melons and dried fruit. Other clues are if the baby has difficulty sleeping, has vomiting, or has diarrhoea or constipation. If there is a combination of these symptoms, then I suggest the mother cuts back on the amount of these foods she eats, or that she feeds to the non breast-fed baby. These foods do not need to be completely avoided. Avoiding dairy and soy in the mother’s diet can also be very helpful, particularly if the baby has blood stained loose stools. If the mother changes her diet, it is important for her to consult a Dietitian experienced in the management of food intolerance, to ensure the best possible nutrition for both the mother and the breast fed baby.

Histamine is used as the positive control for the test. This means that you can only trust the results of the test if the Histamine result is positive. If it were negative, I would suspect the person may have taken antihistamine medications, and all the negative skin prick tests may be false negatives (meaning the whole skin prick test would be unreliable on that occasion). Histamine is used as a “pilot light” for the test. If the “pilot light” does not work, the rest of the test will not work.

This is not an ideal situation but I suggest that the child who brings the peanut butter to school is taken to a safe area to eat by himself, and then the child has his hands and face washed before he is allowed to rejoin the rest of the children. I do not like the allergic children to have to sit by themselves to eat as the allergic child should not be made to feel different or excluded.

Not necessarily. The child who is predisposed to allergy will become allergic to the thing they are exposed to most, and won’t become allergic to something to which they have never been exposed.

This is different in each person, but most children will have some kind of reaction within a few minutes of eating the food to which they are allergic. As soon as you see any sign of a severe allergic reaction (within a couple of minutes) it is important to give the Adrenaline. The longer you wait, the less effective the Adrenaline, and the child will feel sicker for longer. I liken it to trying to stop a train before it gathers too much speed; if you wait for too long the train is too fast and is harder to stop.

You can find information on first aid for allergic reactions at https://www.allergy.org.au/images/pcc/ff/ASCIA_Anaphylaxis_Fast_Facts_2019.pdf

And https://www.allergy.org.au/images/stories/anaphylaxis/2018/ASCIA_PCC_Anaphylaxis_First_Aid_2018.pdf

The tendency to develop allergy is genetic in some cases, and can be inherited in families where there is a history of hay fever, “sinus”, asthma, eczema or food allergy.

This does not mean that the person will be allergic to the same things that the other members of the family are allergic to.

Most children with food allergies travel very safely on airplanes. I advise that families travel early in the morning, as planes are cleaned overnight and therefore the planes are likely to be cleaner for early morning flights. I suggest discussing the child’s allergy with the airline company, to see what the staff will be able to do to accommodate the child’s needs. It may be necessary to take sufficient food and drink for the air travel period, to ensure the child only has safe food and drink. I suggest that children are not allowed to walk around the plane alone as they could pick up food or rubbish from the floor of the plane, or could be offered food by other passengers. I also suggest that the child is given a dose of antihistamine for each of the 3 days leading up to and including the day of any plane trip, to make sure that any reaction which may occur, is less severe. Parents should make sure they take all of the medications they might need to treat an allergic reaction, in the hand luggage so it can be easily accessed during any travel on a plane. You will also need to take all appropriate covering letters from your doctor, to make sure you can take the medications through customs and security onto the plane.

You can find information on safe travel with allergies and asthma at https://www.allergy.org.au/images/stories/anaphylaxis/2016/ASCIA_PCC_Travelling_with_allergy_checklist_2016.pdf

No. Using a wet cloth, or a baby nappy wipe, is sufficient to clean surfaces before they surfaces are touched by the allergic child.

Oral food challenges are done with medical supervision. The aim is to see if a person has a reaction to eating a particular food. In my practice, I use food challenges to establish that a person no longer reacts to a particular food (“has outgrown the allergy”). If there is some doubt about the diagnosis of food allergy in the first place, it is sometimes appropriate to do a food challenge, but only under medical supervision. In most cases it is obvious whether a child has true allergy or not, from the history supplied by the parents. Blood testing can be helpful in deciding whether a food challenge will be appropriate in showing the absence of allergy.

You can find information on food challenges at https://www.allergy.org.au/images/pcc/ASCIA_PCC_Food_allergen_challenges_FAQs_2019.pdf

Behaviour problems are occasionally caused by food intolerance. In the majority of people, changing the diet will not be effective. If you want to change the diet, many people start by avoiding all additives (colours, flavours, and preservatives) in foods the child eats. If you want to make other changes to the diet, it is best that you consult a Dietitian experienced in the use of an elimination diet as these can be very restrictive and can lead to poor nutrition. These restrictive diets should not be continued long term, and should always be followed by food challenges to see what exactly affects the child in which way, and will allow a fuller (more complete or nutritious) diet in most children.

You should make sure you have removed the blue safety cap from the end of the Epipen, and make sure the orange end of the Epipen is applied firmly to the child’s upper outer thigh, and then pressed firmly into the thigh until a loud click is heard. The Epipen should then be held in place for 3 seconds to allow all of the adrenaline to be injected into the child.

Make sure you call an ambulance to take the child to hospital immediately after using the Epipen.

A child can be given paracetamol (the same active ingredient as Panadol syrup) by dissolving a white Paracetamol tablet in water, then giving the appropriate dose to the child, by mouth. If you crush a single 500mg paracetamol tablet and mix it in 10ml of cooled boiled water, you can give a dose of 2ml per 10kg body weight, every 4 hours as needed. On average, this means that a 12 month old person would have 2ml every 4 hours. A 2 year old weighing 15kg would have a dose of 3ml every 4 hours as needed. A 4 year old, weighing 20kg, would have 4ml every 4 hours as needed. The appropriate dose for your child can be calculated according to weight. You can also get a Compounding Pharmacist to make up unflavoured colour free Paracetamol suspension.

The special formulas made without milk or soy taste very different from normal baby formula. They look “thinner” than normal formula and smell very different. It can take several weeks for some children to take the formulas so the parents need to be very persistent in giving them to the baby. It is best if they are given cool (too warm makes the taste stronger) and best if they are mixed with 2 heaped teaspoons of icing sugar in each bottle. This will not be needed forever. As soon as the child accepts the formula, the parent should slowly start to wean the child off the sugar. I liken it to a teenager starting to drink coffee. As coffee is bitter, the teenager will probably want sugar in the coffee for a while but as his taste “matures” the sugar can gradually be removed. It can be useful to mix small amounts of the new formula into the child’s usual formula, or expressed breast milk, and gradually change the balance, increasing the new formula and decreasing the old formula over a few weeks. This will not be appropriate if the child is actually allergic to the old formula (hives or swelling when exposed to the old formula). In that case, the old formula needs to be stopped altogether.

More hints are available at https://neocatevillage.com.au/tips/using-neocate-for-the-first-time/

Desensitisation (“immunotherapy”) is given in two different ways. There is a chance of side effects with both methods of giving the therapy. Injectable immunotherapy carries a higher rate of reactions in comparison to the sublingual (“under the tongue”) method. The most common reaction to the injections is an itchy lump at the site of the injection. There are some people who have more severe reactions, including a feeling of faintness and some shortness of breath or wheeze. For people who take their treatment by the sublingual method, the most common reaction is some itch under the tongue and perhaps some nausea. It is very unlikely that a person would have a severe allergic reaction to taking their immunotherapy under the tongue. In both methods of immunotherapy, I recommend taking a dose of antihistamine about 30 minutes before the treatment; I also ask that the patient does not exercise for 2 hours after each injection, and I get them to stay under my observation for at least 30 minutes after each injection.

Some more information is found at

https://www.allergy.org.au/images/pcc/ff/ASCIA_Allergy_Treatments_Fast_Facts_2019.pdf

and

https://www.allergy.org.au/images/pcc/ASCIA_PCC_Allergen_Immunotherapy_2019.pdf

If there is peanut butter brought to school, there is a small chance that small amounts of peanut butter will be spread around the school on surfaces. If the allergic child touches some peanut butter, it is likely the reaction would be a skin rash. More severe reactions usually only happen in certain children, if the peanut butter is actually eaten. Smelling peanut butter is not likely to cause a reaction.

Eczema is a skin condition, which causes itch, and rash, and is often associated with allergy to dust mite or to foods. In small babies, it often affects the face and the neck. As children get older, the skin in the fold of the elbows and knees is likely to also be affected.

https://www.allergy.org.au/images/pcc/ff/ASCIA_Eczema_Fast_Facts_2019.pdf

Children who are allergic to one nut are not necessarily allergic to other nuts. There is no good answer to this question, but in most cases it is not necessary for the child to avoid eating other nuts.

Adrenaline should always be the first medicine used to control a severe allergic reaction. In some cases more than one dose is needed. The main thing to remember is that there is less chance of the Adrenaline working well enough if there is delay in giving it. If there is even one symptom of a severe allergic reaction (you need to look at your written Allergy Action Plan) you should give the Adrenaline without delay. IF IN DOUBT, USE THE EPIPEN. THERE IS MORE HARM IN NOT GIVING IT THAN IN GIVING THE ADRENALINE EVEN IF IT IS NOT NEEDED.

https://www.allergy.org.au/images/pcc/ff/ASCIA_Anaphylaxis_Fast_Facts_2019.pdf

Some people are prone to developing allergy. He reason for this is not fully understood, but it is likely to be due to several different factors in any one person. There is a genetic component in many people (a family history of asthma, eczema, hay fever, “sinus” or food allergy) and if these people are exposed to certain foods or other substances, the body recognizes these substances as “foreign invaders” and sets up a reaction against them, to “fight them off”. These reactions then start to damage the body itself. It is not possible to be allergic to something the body has never been exposed to.

Antihistamines are medications that stop the effect of histamine in the body. Histamine is a natural substance that certain blood cells make. It is released when these blood cells are provoked by exposure to something to which the person is allergic. Antihistamines help to control symptoms of allergic reactions. Some have better effects on itch (mostly the sedating antihistamines) and some are non sedating and better for people who need to continue to work or go to school despite having the medication.

There is a use by date on the side of each of these devices. Make sure you know when the device expires and get a new prescription before that date. You should join www.epiclub.com.au; this will allow you to register your Epipen batch for you and will send you a reminder when the expiry date is getting close.

You can also get reminders through the Allergy Pal app.

ASCIA recommends that a child should change to having an adult size Epipen when their body weight is 20kg or more, as the Junior Epipen dose would be too small for those weighing more than 20kg.

An Epipen is an Adrenaline auto injector device. It delivers a single dose of Adrenaline; it is used for the treatment of severe allergic reactions, prior to the patient being taken to hospital. Each Epipen can only be used once and then needs to be discarded and replaced. In some cases a person needs to be treated with more than one dose of Epipen.

Asthma is a common respiratory illness, involving inflammation and tightening of the small lung passages. Often people with asthma have cough and wheeze with exercise or with colds and flu like illnesses, but children can have asthma without wheeze. I become suspicious that a person may have asthma if they have cough in the middle of the night for a few weeks at a time, or if they cough with exercise, particularly in the late afternoon if it is cold. Some children will limit the amount of exercise they do so they do not have symptoms, so looking at their ability to keep up with the other children at school when they exercise can often give a hint the child may have asthma.

https://www.allergy.org.au/images/pcc/ff/ASCIA_Asthma_and_Allergy_Fast_Facts_2019.pdf

This question is difficult to answer as every child and every family is different. It very much depends on the history of the person in question; if they have required more than one Epipen to be used to treat any one allergic reaction, then the child should have at least that many Epipens available to treat future reactions. There has been a suggestion that children with difficult to treat asthma should carry more than one Epipen, as there is a risk of around 20% that the child will need to have treatment with 2 or more adrenaline injections in any one allergic reaction. Nonetheless, the Federal Government Pharmaceutical Benefits Scheme allows for the subsidised purchase of only 2 adrenaline auto injectors to be held by a family at any one time for any one child (one for home and one for school). If the parent wants to purchase more then the family will need to buy the extra auto injector devices privately from the Pharmacy, at full cost.

There is a chance the person will need more than one injection of Adrenaline, or other treatments for any particular severe allergic reaction. For that reason a person should be observed carefully in hospital for at least 4 hours after any reaction to ensure they are not becoming sick again, or needing any extra treatment. Staying in the waiting room of the doctor’s office does not give the proper amount of direct observation, and does not allow for the person to lie down and rest. More equipment and staff are available at a hospital to treat a person with a severe allergic reaction, than at the average GP’s office. I recommend that if a person goes to a GP to have treatment of a severe allergic reaction, the GP should call an ambulance to transport the patient to hospital as soon as practical after the appropriate emergency treatment has been administered.

A person with asthma has a 20% chance of needing a second dose of Adrenaline to treat any severe allergic reaction. I recommend that these children stay in hospital for a full 12 hours observation to ensure there is no need to treat them again with Adrenaline, for a rebound or “late phase” reaction.