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Testing for food allergy

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These are the paths in the Food allergy in children and young people pathway:

Food allergy in children and young people HAI

About

What is covered

This pathway covers the diagnosis and assessment of food allergy in children and young people (from birth up to their 19th birthday) in primary care and community settings.
Food allergy is an adverse immune response to a food. Food allergy is one of the most common allergic disorders and is recognised as a major paediatric problem in western countries. Its prevalence has increased dramatically in recent decades. There is great variation in current practice for allergy care, and there are no agreed treatment pathways or referral criteria. Many people use alternative sources of support instead of NHS services, including non-validated tests and treatments.

Updates

Updates to this pathway

22 July 2014 Link to constipation pathway added
21 February 2014 Minor maintenance update
13 September 2013 Minor maintenance update
3 September 2013 Quality standard for atopic eczema in children (QS44) added to pathway
8 February 2013 Minor maintenance updates
5 March 2012 Minor maintenance updates

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Diagnosis and assessment of food allergy in children and young people in primary care and community settings

What is covered

This pathway covers the diagnosis and assessment of food allergy in children and young people (from birth up to their 19th birthday) in primary care and community settings.
Food allergy is an adverse immune response to a food. Food allergy is one of the most common allergic disorders and is recognised as a major paediatric problem in western countries. Its prevalence has increased dramatically in recent decades. There is great variation in current practice for allergy care, and there are no agreed treatment pathways or referral criteria. Many people use alternative sources of support instead of NHS services, including non-validated tests and treatments.

Updates

Updates to this pathway

22 July 2014 Link to constipation pathway added
21 February 2014 Minor maintenance update
13 September 2013 Minor maintenance update
3 September 2013 Quality standard for atopic eczema in children (QS44) added to pathway
8 February 2013 Minor maintenance updates
5 March 2012 Minor maintenance updates

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Food allergy in children and young people. NICE clinical guideline 116 (2011)

Quality standards

Atopic eczema in children quality standard

These quality statements are taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statements

Assessment at diagnosis

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.

Rationale

Recording a child's detailed clinical and treatment history as part of the assessment in all healthcare settings is an important step in the management of atopic eczema in children. At the diagnosis stage, assessing potential trigger factors, including irritants and allergens, will lead to better management and potentially lead to a reduction in the severity of the atopic eczema experienced by the child.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema are offered, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Data source: Local data collection.
Process
The proportion of children with atopic eczema who receive, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Numerator: the number of children in the denominator who receive, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Denominator: the number of children with newly diagnosed atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Healthcare practitioners offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.
Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema, at diagnosis, an assessment that includes recording of their detailed clinical and treatment histories and identification of potential trigger factors.

What the quality statement means for patients and carers

Children with atopic eczema are offered an assessment, in which their healthcare professional records their detailed medical and treatment histories and identifies any factors that might trigger their eczema.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.1.1.1 and 1.4.1.1 (key priority for implementation).

Definitions

Clinical and treatment histories
NICE clinical guideline 57 recommends that healthcare practitioners take detailed clinical and treatment histories at diagnosis to aid management of atopic eczema in children, and that these should include questions about:
  • time of onset, pattern and severity of the atopic eczema
  • response to previous and current treatments
  • possible trigger factors (irritant and allergic)
  • the impact of the atopic eczema on children and their parents or carers and families
  • dietary history including any dietary manipulation
  • growth and development
  • personal and family history of atopic diseases.
Potential trigger factors
NICE clinical guideline 57 recommends that when clinically assessing children with atopic eczema, healthcare practitioners should seek to identify potential trigger factors including irritants, for example soaps and detergents, skin infections and contact, food and inhalant allergens. In addition, the expert opinion of the Topic Expert Group stated that psychological stress can cause flares of atopic eczema, and should be avoided where possible.

Stepped approach to management

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.

Rationale

Atopic eczema is typically an episodic condition consisting of flares and remissions, though in some children it is continuous. Treatment for atopic eczema should be tailored, with treatments stepped up and down according to the recorded severity of symptoms. Areas of atopic eczema of differing severity can coexist in the same child, and each area should be treated independently. The stepped-care plan involves self-management and adherence to treatment, therefore healthcare practitioners should give children with atopic eczema and their families or carers support and information on when and how to step treatment up or down.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema are offered treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Data source: Local data collection.

Process

(a) The proportion of children with atopic eczema who have their eczema severity recorded at each eczema consultation.
Numerator: the number of children in the denominator who have their eczema severity recorded at each eczema consultation.
Denominator: the number of eczema consultations with children with atopic eczema.
Data source: Local data collection.
(b) The proportion of children with atopic eczema who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Numerator: the number of children in the denominator who receive treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Denominator: the number of children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Healthcare practitioners offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.
Commissioners ensure that they commission services with local arrangements to offer children with atopic eczema treatment based on recorded eczema severity using the stepped-care plan, supported by education.

What the quality statement means for patients and carers

Children with atopic eczema are offered treatment using a stepped-care plan (which means that treatments are added or stopped depending on how severe the eczema is) and given advice and information about atopic eczema and its treatment.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.2.1.1 (key priority for implementation), 1.2.1.3 and 1.5.1.1 (key priority for implementation).

Definitions

Eczema severity
NICE clinical guideline 57 recommends an assessment of the physical severity of atopic eczema and the impact of atopic eczema on quality of life and social wellbeing at each eczema consultation. The guideline defines the physical severity of atopic eczema as follows:
  • Clear: normal skin, no evidence of active atopic eczema
  • Mild: areas of dry skin, infrequent itching (with or without small areas of redness)
  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).
Stepped approach to management
NICE clinical guideline 57 recommends that healthcare practitioners use a stepped approach to managing atopic eczema in children, which means tailoring the treatment step to the severity of the atopic eczema. Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Management can then be stepped up or down, according to the severity of symptoms, by adding or withdrawing treatments as follows (phototherapy and systemic therapy should be undertaken only under specialist dermatological supervision by staff who are experienced in dealing with children):
Mild atopic eczema
Moderate atopic eczema
Severe atopic eczema
Emollients
Emollients
Emollients
Mild-potency topical corticosteroids
Moderate-potency topical corticosteroids
Potent topical corticosteroids
Topical calcineurin inhibitors
Topical calcineurin inhibitors
Bandages
Bandages
Phototherapy
Systemic therapy
Healthcare practitioners should review repeat prescriptions of individual products and combinations of products with children with atopic eczema (and their parents or carers) at least once a year to ensure that treatment remains optimal
Supported by education
Education on the use of, and adherence to, treatment is essential to the stepped-care plan approach. NICE clinical guideline 57 recommends that healthcare practitioners offer children with atopic eczema (and their parents or carers) information on how to recognise the symptoms and signs of bacterial infection and also how to recognise and manage flares of atopic eczema according to the stepped-care plan. Healthcare practitioners should spend time educating children with atopic eczema (and their parents or carers) about atopic eczema and its treatment. They should provide information in verbal and written forms, with practical demonstrations, and should cover:
  • how much of the treatments to use
  • how to apply and how often to apply prescribed treatments, including emollients, steroids, calcineurin inhibitors and medicated dressings (bandages)
  • when and how to step treatment up or down
  • how to treat infected atopic eczema.
This should be reinforced at every consultation, addressing factors that affect adherence.

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.
In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.

Psychological wellbeing and quality of life

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with atopic eczema have their (and their families') psychological wellbeing and quality of life discussed and recorded at each eczema consultation.

Rationale

Healthcare practitioners should adopt a holistic approach when assessing a child's atopic eczema at each eczema consultation, taking into account the severity of the atopic eczema and the impact on the child's quality of life. Atopic eczema can have a negative psychological effect on children and their families or carers. Discussing and recording the impact of the atopic eczema (even if its physical severity is mild) on psychological and psychosocial wellbeing and quality of life is an essential part of a holistic approach, and can inform treatment strategies.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema have their (and their families') psychological wellbeing and quality of life discussed and recorded at each eczema consultation.
Data source: Local data collection.

Process

The proportion of eczema consultations with children with atopic eczema at which their (and their families') psychological wellbeing and quality of life is discussed and recorded.
Numerator: the number of consultations in the denominator at which children's (and their families') psychological wellbeing and quality of life is discussed and recorded.
Denominator: the number of eczema consultations with children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place for children with atopic eczema and their families to be asked about their psychological wellbeing and quality of life, and for this to be recorded at each eczema consultation.
Healthcare practitioners ensure that children with atopic eczema and their families are asked their psychological wellbeing and quality of life, and that this is recorded at each eczema consultation.
Commissioners ensure that they commission services with local arrangements for children with atopic eczema and their families to be asked about their psychological wellbeing and quality of life, and for this to be recorded at each eczema consultation.

What the quality statement means for patients and carers

Children with atopic eczema and families and/or carers are asked about how they are feeling and how the eczema is affecting their lives on a day-to-day basis, and have this recorded at each eczema consultation.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.2.1.1 (key priority for implementation), 1.2.1.4 and 1.2.1.5.

Definitions

Psychological wellbeing and quality of life
NICE clinical guideline 57 recommends that healthcare practitioners should adopt a holistic approach when assessing a child's atopic eczema at each consultation. Healthcare practitioners should take account of the child's quality of life, including everyday activities and sleep, and psychosocial wellbeing, as well as the physical severity of their condition. There is not necessarily a direct relationship between the severity of atopic eczema and its impact of quality of life. Even mild atopic eczema can have a negative impact on psychological and psychosocial wellbeing and quality of life.
The guideline defines the impact of atopic eczema on quality of life and psychosocial wellbeing as follows:
  • None: no impact on quality of life
  • Mild: little impact on everyday activities, sleep and psychosocial wellbeing
  • Moderate: moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
  • Severe: severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep.
The guideline recommends that healthcare practitioners take into account the impact of atopic eczema on parents or carers as well as the child.
In the opinion of the Topic Expert Group, the impact of atopic eczema on families and/or their carers will usually be recorded in the notes of the child who has atopic eczema.

Provision of emollients

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with atopic eczema are prescribed sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.

Rationale

Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear. Children with atopic eczema should have sufficient quantities of emollients for everyday use. These should be suited to the child's needs and preferences, with alternatives offered if a particular emollient causes irritation or is not acceptable to a child.

Quality measures

Structure
Evidence of local arrangements to prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Data source: Local data collection.

Process

The proportion of children with atopic eczema who are prescribed sufficient quantities (250–500 g weekly) of unperfumed emollients for daily use.
Numerator: the number of children in the denominator who are prescribed sufficient quantities (250–500 g weekly) of unperfumed emollients for daily use.
Denominator: the number of children with atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place to prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Healthcare practitioners ensure that they prescribe children with atopic eczema sufficient quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.
Commissioners ensure that they commission services with local arrangements for children with atopic eczema to be prescribed with sufficient prescribed quantities (250–500 g weekly) from a choice of unperfumed emollients for daily use.

What the quality statement means for patients and carers

Children with atopic eczema receive a prescription for enough (between 250 g and 500 g weekly) unperfumed emollient (a special type of skin moisturiser) chosen to best suit their needs and preferences for daily use.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.5.1.1, 1.5.2.1 (key priorities for implementation) and 1.5.2.2.

Definitions

Unperfumed emollients
NICE clinical guideline 57 recommends that a choice of unperfumed emollients should be offered to children with atopic eczema that is suited to the child's needs and preferences for everyday moisturising, washing and bathing. This may include a combination of products or 1 product for all purposes.
The guideline adds that healthcare practitioners should offer an alternative emollient if a particular emollient causes irritation or is not acceptable to a child with atopic eczema.
Leave-on emollients should not be of a type that can cause harm to a child's skin. The full NICE guideline states that aqueous cream is associated with stinging when used as a leave-on emollient but it can be used as a wash product. Since the publication of the guideline there has been increasing concern about the use of sodium lauryl sulfate as an emulsifier (a substance used to mix oil with water to make creams) and an MHRA drug safety update in March 2013 advises that if a patient reports or shows signs of skin irritation with the use of aqueous cream, treatment should be discontinued and an alternative emollient that does not contain sodium lauryl sulfate should be tried.

Equality and diversity considerations

In recommending skin treatments, healthcare practitioners should be sensitive to the cultural practices of families or carers of children with atopic eczema. For example, if families or carers use olive oil as a skin treatment (which is likely to be harmful to a child's skin) or if they rinse children after bathing (rinsing off emollients), the reasons for using the recommended treatment and applying it correctly should be explained sensitively.

Referral for specialist dermatological advice

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.

Rationale

Specialist dermatological advice may be beneficial for children with atopic eczema to improve the management of their condition. It can help to identify underlying reasons why the atopic eczema is not well controlled (including trigger factors such as contact allergens) or provide support if the condition has a negative impact on quality of life and psychosocial wellbeing. Parents' or carers' assessments of a child's physical or psychosocial wellbeing should be regarded as important determinants of the need for specialist dermatological advice.

Quality measures

Structure
Evidence of local arrangements for children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema to be referred for specialist dermatological advice.
Data source: Local data collection.

Process

The proportion of children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema who are referred for specialist dermatological advice.
Numerator: the number of children in the denominator who are referred for specialist dermatological advice.
Denominator: the number of children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that there are local arrangements for children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema to be referred for specialist dermatological advice.
Healthcare practitioners ensure that children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema are referred for specialist dermatological advice.
Commissioners ensure that they commission services with local arrangements to refer children with uncontrolled or unresponsive atopic eczema, including recurring infections, or psychosocial problems related to the atopic eczema for specialist dermatological advice.

What the quality statement means for patients and carers

Children with atopic eczema whose eczema does not improve after treatment, becomes infected repeatedly or causes them social or psychological problems are referred to a specialist.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.7.1.3 (key priority for implementation) 1.7.1.2 and 1.4.1.5 .

Definitions

Specialist dermatological advice
The referral should be to a specialist dermatological unit dealing with paediatric patients, for example a clinician with experience or qualifications in paediatric dermatology. This could include a paediatrician, specialist nurse or a GP with a specialist interest as long as they are within a dermatological unit and trained in paediatric dermatology.
NICE clinical guideline 57 recommends referral for specialist dermatological advice if the atopic eczema is not well controlled (including as assessed by the child, parent or carer), has not responded to treatment, is associated with recurring infections or if contact allergic dermatitis is suspected. Specialist dermatological advice should also be sought if the physical condition is giving rise to significant social or psychological problems for the child (or their parents or carers), including sleep disturbance or poor school attendance.
Onward referral for psychological advice can be made if necessary. NICE clinical guideline 57 recommends that children with atopic eczema that has responded to optimum management but for whom the impact of the atopic eczema on quality of life and psychosocial wellbeing has not improved should be referred for psychological advice.

Equality and diversity considerations

Healthcare practitioners should be aware of the potential difficulties of assessing eczema severity in children with darker skin tones.
Parent or carer assessment should be considered a good indicator of need for referral for all children. This must apply equally to all children regardless of socioeconomic status, and should not depend on the parents' or carers' ability to articulate a need for specialist care.

Specialist allergy investigation

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergies.

Rationale

Infants and young children with moderate or severe atopic eczema have an increased likelihood of food and other allergies. Food allergies can cause a range of symptoms, including anaphylaxis, and can trigger or exacerbate atopic eczema. The most common food allergies for infants and young children with atopic eczema are to cows' milk, hens' eggs and nuts.
Specialist investigation can provide accurate identification of common food and other allergies; advice on dietary avoidance of allergens and choice of infant formula; and improved condition management strategies.

Quality measures

Structure
Evidence of local arrangements for infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment to be referred for specialist investigation to identify possible food and other allergies.
Data source: Local data collection.

Process

The proportion of infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment who are referred for specialist investigation to identify possible food and other allergies.
Numerator: the number of infants and young children in the denominator who are referred for specialist investigation to identify possible food and other allergies.
Denominator: the number of infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that there are local arrangements for infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment to be referred for specialist investigation to identify possible food and other allergies.
Healthcare practitioners ensure that infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment are referred for specialist investigation to identify possible food and other allergies.
Commissioners ensure that they commission services with local arrangements to offer infants and young children with moderate or severe atopic eczema that has not been controlled by optimal treatment referral for specialist investigation to identify possible food and other allergies.

What the quality statement means for patients and carers

Infants and young children with moderate or severe atopic eczema that has not improved after treatment are referred to a specialist to find out whether they have any allergies that may be causing their eczema.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.4.1.2 (key priority for implementation), 1.7.1.3 (key priority for implementation) 1.7.1.5, 1.4.1.5, 1.4.1.7 and 1.4.1.8.

Definitions

Infants and young children
NICE clinical guideline 57 refers to a possible diagnosis of food allergy in infants and young children. The consensus of the quality standard Topic Expert Group is that this refers to children aged under 5 years.
Moderate or severe atopic eczema
NICE clinical guideline 57 defines moderate and severe atopic eczema as follows:
  • Moderate: areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
  • Severe: widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation).
Optimal treatment
Optimal treatment for atopic eczema for infants and young children refers to the stepped-care plan.
Specialist investigation
Referral for investigation into suspected food allergies may be to either a paediatric allergist or paediatric dermatologist, depending on the local availability of services. Other associated allergies (such as those to pollens or house dust mite) can also be investigated at the same time. Access to specialist allergy nurses and dieticians would normally be through the allergy team rather than a direct referral by a GP.

Treatment of eczema herpeticum

This quality statement is taken from the atopic eczema in children quality standard. The quality standard defines clinical best practice for atopic eczema in children and should be read in full.

Quality statement

Children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.

Rationale

Eczema herpeticum (widespread herpes simplex virus) is a serious under-recognised condition and, if not diagnosed promptly, the child's condition may deteriorate rapidly. Eczema herpeticum can be fatal or can lead to blindness if not treated, and should therefore be an indication for urgent referral.

Quality measures

Structure
Evidence of local arrangements to ensure that children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Data source: Local data collection.

Process

The proportion of children with atopic eczema who have suspected eczema herpeticum who receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Numerator: the number of children in the denominator who receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Denominator: the number of children with atopic eczema who have suspected eczema herpeticum.
Data source: Local data collection.

Outcome

Deaths of children with atopic eczema from eczema herpeticum.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that local arrangements are in place for children with atopic eczema who have suspected eczema herpeticum to receive immediate treatment with systemic aciclovir and to be referred for same-day specialist dermatological advice.
Healthcare practitioners ensure that children with atopic eczema who have suspected eczema herpeticum receive immediate treatment with systemic aciclovir and are referred for same-day specialist dermatological advice.
Commissioners ensure that they commission services with local arrangements to give children with atopic eczema who have suspected eczema herpeticum immediate treatment with systemic aciclovir and to refer them for same-day specialist dermatological advice.

What the quality statement means for patients and carers

Children with atopic eczema who have suspected eczema herpeticum (a rare but serious infection caused by the same virus that causes cold sores) receive immediate treatment with an antiviral drug (called systemic aciclovir), which can be given as medicine or an injection, and are referred immediately for same-day specialist advice.

Source guidance

Atopic eczema in children (NICE clinical guideline 57), recommendations 1.5.7.10, 1.5.7.11 1.5.7.12 (key priority for implementation) and 1.7.1.1.

Definitions

Suspected eczema herpeticum
Eczema herpeticum is a widespread herpes simplex virus. Signs of eczema herpeticum are:
  • areas of rapidly worsening, painful eczema
  • clustered blisters consistent with early-stage cold sores
  • punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm that are uniform in appearance (these may coalesce to form larger areas of erosion with crusting)
  • possible fever, lethargy or distress.
Specialist dermatological advice
The referral should be to a specialist dermatological unit dealing with paediatric patients, for example, a clinician with experience and qualifications in paediatric dermatology. This could include a specialist nurse or a GP with a specialist interest if they are working within a dermatological unit and trained in paediatric dermatology. If eczema herpeticum involves the skin around the eyes, the child should be referred for same-day ophthalmological and dermatological advice.
Systemic aciclovir
Oral or intravenous aciclovir can be given depending on the clinical situation. Aciclovir is likely to be given orally in primary care and intravenously in secondary care. The full NICE guideline recommends that if a child with atopic eczema has a lesion on the skin suspected to be herpes simplex virus, treatment with oral aciclovir should be started even if the infection is localised.

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Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Signs and symptoms of possible food allergy

Note: this list is not exhaustive. The absence of these symptoms does not exclude food allergy.
The skin
Acute urticaria (localised or generalised)
Acute angioedema (most commonly in the lips and face, and around the eyes)
Pruritus
Erythema
The gastrointestinal system
Angioedema of the lips, tongue and palate
Oral pruritus
Nausea
Colicky abdominal pain
Vomiting
Diarrhoea
Loose or frequent stools
Blood and/or mucus in stools
Abdominal pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor and tiredness
Faltering growth plus one or more gastrointestinal symptoms above (with or without significant atopic eczema)
The respiratory system (usually in combination with one or more of the above symptoms and signs)
Upper respiratory tract symptoms – nasal itching, sneezing, rhinorrhoea or congestion (with or without conjunctivitis)
Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)
Other
Signs or symptoms of anaphylaxis or other systemic allergic reactions

Glossary

A severe, life-threatening, generalised or systemic hypersensitivity reaction, characterised by rapidly developing life-threatening airway, breathing and/or circulation problems, usually associated with skin and mucosal changes.
Swelling, similar to hives, except that the swelling is beneath the skin rather than on the surface.
A chronic inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as folds of elbows or behind the knees. The word 'atopic' in the term atopic eczema is an indicator of the frequent association with atopy and the need to separate this clinical phenotype from the ten or so other forms of eczema such as irritant, allergic contact, discoid, venous, seborrhoeic and photosensitive eczema. The terms 'atopic eczema' and 'atopic dermatitis' are synonymous.
Allergies that are commonly found to be present in association with other allergies.
Redness.
An adverse immune response to a food. It can be classified into IgE-mediated and non-IgE-mediated reactions. IgE-mediated reactions are triggered by the immunoglobulin E (IgE) antibody and are acute, frequently with rapid onset. Non-IgE-mediated reactions are usually caused by cell reactions in the immune system and are generally characterised by delayed and non-acute reactions.
A chronic digestive disease that occurs when the contents of the stomach, including acid, flows back (refluxes) into the oesophagus (gullet).
Immunoglobulin E (IgE) is a class of antibody. It triggers an excessive activation of certain white blood cells called mast cells and basophils resulting in an extreme inflammatory response.
An allergic reaction triggered by the immunoglobulin E (IgE) antibody. The reaction is acute and frequently has rapid onset.
Mixed reactions involve a mixture of both IgE and non-IgE responses.
This type of allergy is not caused by IgE antibodies (it is usually because of cell reactions in the immune system).These reactions are generally characterised by delayed and non-acute reactions.
Itchy skin.
Allergic reactions involving parts of the body distant to the actual site of allergen contact.
Raised, red, itchy welts (weals or swellings) of various sizes that seem to appear and disappear on the skin.

Paths in this pathway

Pathway created: December 2011 Last updated: July 2014

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