Food allergy in under 19s: assessment and diagnosis

Search and selection strategy

Using the static list process, we searched for new Cochrane reviews related to the whole guideline. We found no relevant Cochrane reviews published between January 2011 and May 2018.

The surveillance review in 2014 did not identify any new studies.

We also considered studies identified in the 2012 evidence update for NICE guideline CG116, which were not considered to have an impact on recommendations.

Views of topic experts

We sent questionnaires to 11 topic experts and received 5 responses. The topic experts either:

Four of 5 experts suggested that the guideline should be updated. Topic experts indicated NICE guideline CG116 could include the management and treatment of food allergy in primary care, and changes could be informed by the more recent food allergy-related guidelines. However, prevention, management and treatment of food allergy is outside the remit of NICE guideline CG116; the remit covers assessment and diagnosis only. There are no future plans to modify the remit of this guideline to include management and treatment of food allergy.

Experts also suggested that cross references could be included for information to British Society for Allergy and Clinical Immunology (BSACI) guidelines (Clark et al. 2010, Luyt et al. 2014 and Stiefel et al. 2017) and Milk Allergy in Primary Care (MAP) guidelines (Venter et al. 2017 and Venter et al. 2013). The NICE accredited BSACI guidelines are considered partially relevant to NICE guideline CG116, but were primarily developed for secondary and tertiary care audiences and were broader in their scope as they covered management of food allergies. Additionally, cross references to external sources are difficult to manage when changes occur. We have not added cross references to external guidelines at this time.

Topic experts noted that good quality clinical research in food allergy assessment and diagnosis in children remains very limited and inevitably there has been significant reliance on consensus expert opinion.

Experts indicated that some inconsistencies exist between NICE guideline CG116 and more recent NICE products on food allergy:

Detailed comments were received from 4 of 5 topic experts suggesting changes to recommendations. In some areas the text could be refreshed to address the comments (see editorial amendments), although other changes will not be actioned as they would require new supporting evidence. The changes we adopted include:

The suggested changes that we did not adopt, as we did not identify evidence to support them, include:

Views of stakeholders

Stakeholders are consulted on all surveillance decisions except if the whole guideline will be updated and replaced. Because this surveillance decision was to not update the guideline, we consulted on the decision.

Overall, 9 stakeholders commented; of these, 3 represented a charity organisation, 1 was a government organisation and 5 were professional bodies. Four stakeholders agreed with the decision to not update the guideline, 2 disagreed and 3 did not state a response.

One stakeholder advised that cross references should be added from NICE guideline CG116 to NICE's guideline on coeliac disease: recognition, assessment and management. We outline where cross references have been added to this guideline in the editorial amendments section.

Two stakeholders suggested that the guideline should recommend that atopy patch testing should not be used to diagnose IgE-mediated and non-IgE-mediated food allergy in primary care or community settings. The guideline does not recommend the use of atopy patch testing for either IgE or non-IgE food allergy. Recommendation 1.1.10 states: 'Do not use atopy patch testing or oral food challenges to diagnose IgE-mediated food allergy in primary care or community settings'. Furthermore, we have not received any implementation data to indicate that professionals are using atopy patch testing to diagnose non-IgE-mediated food allergy in primary care and community settings, as a result of misunderstanding the guideline. We have not identified evidence that would merit changes to the guideline regarding atopy patch testing at this time.

One stakeholder suggested that recommendation 1.1.18 should be broadened to mention further diagnostic tools that should not be used. This included bioresonance testing and bioelectric impedance measurement. We have not identified evidence that would support changes to recommendation 1.1.18 or 1.1.19, and do not plan to make changes to recommendations about alternative diagnostic tools at this time.

We consulted stakeholders on a proposed change to the term 'acute' and 'non-acute' in the context of food reactions mentioned in the guideline; the text stated: 'Food allergy can be classified into IgE-mediated and non-IgE-mediated allergy. IgE-mediated reactions are acute and frequently have a rapid onset. Non-IgE-mediated reactions are generally characterised by delayed and non-acute reactions'. Five stakeholders provided a response and all agreed that the text should be revised. Reference to the term 'acute' and 'non-acute' in the context of food reactions will therefore be replaced with 'immediate' to describe IgE-mediated reactions and 'delayed' for non-IgE-mediated. The revised text in the guideline will state: 'Food allergy can be classified into IgE-mediated and non-IgE-mediated allergy. IgE-mediated reactions are frequently immediate and have a rapid onset. Non-IgE-mediated reactions are generally characterised by delayed reactions'.

See appendix A for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

No equalities issues were identified during the surveillance process.

Editorial amendments

During surveillance of the guideline we identified the following points in the guideline that should be amended.