Care and mobility considerations
Food Allergy
‘The acquisition, preparation and consumption of food are a fundamental and unavoidable part of life.’ [Hourihane] Consequently this issue of allergy to food cannot be avoided or ignored but must be faced every time the child eats. It can significantly increase care needs of a child with a food allergy. The effect of the allergy on care will depend on the age of the child and the severity and number of food allergies diagnosed.
Food allergy related care needs - children aged 3 to 8
Children diagnosed with an allergy where there is no risk of anaphylaxis as assessed by the treating allergist will not require significantly more care. This is a mild condition.
For more information see Various scenarios
Children who have been diagnosed as at risk of anaphylaxis will require extra care and supervision at all times until they are older than a child without allergies. All children require constant supervision until the age of 3 because of the risk of choking on food and non-food items. This supervision will continue for a child at risk as the parent will be monitoring for an additional hazard (food allergen) that the child has not yet learnt to avoid.
The child at risk will require extra supervision to prevent allergen exposure until she/he can reliably avoid known hazards or communicate hazards to people she/he does not know well. At age 5, normally developing children can communicate well with people they know and generally avoid hazards by themselves. At age eight, they can reliably communicate with people they do not know well. A child could be expected to take on avoiding allergens and communicating effectively about their allergy between the age of 4 and 8 years. Supervision is required during waking hours and it would be expected that the child’s bedroom is kept free from potential hazards at night. It would also be expected that the home environment is generally kept allergen free but most accidental food allergy reactions occur at home. Depending on the severity of the allergy, the parent may not feel comfortable allowing the child to be supervised by people the child does not know well because of worries over communication related to avoidance of allergens or an allergic reaction. Children can communicate more reliably with strangers by age 8 years. Children with learning and behavioural difficulties may require supervision beyond this age. Such supervision of allergic children may seem excessive but as most fatal reactions occur outside the home and to teenagers and young adults, it may be that this extra care substantially prevents severe reactions at a young age. The diagnosis of an allergy will certainly cause anxiety and extra care and supervision will be needed to prevent harm to young children at risk.
Severity of the functional restriction
For any child with a food allergy, avoidance of the allergen will be key to continuing health and this may be very easy to do and the consequences of failing to avoid the food may be mild. The main assessment will be whether the child has been diagnosed with a food allergy and whether the medical evidence supports a risk of anaphylaxis. If there is a risk of anaphylaxis, the difficulty of avoiding the allergen should be assessed. Table 2 in the link below provides information about the risk of anaphylaxis associated with certain foods and with environmental contamination.
Supervision required will depend on what dose of allergen is required for anaphylaxis to occur and whether the child reacts to food allergens in the environment without eating the food. The vast majority of children will need to eat a food item containing the allergen to have anaphylaxis - even if only a trace of the allergen is present in the food. This means a child can keep themselves safe by not eating if necessary. This is a moderate condition.
For more information see Various scenarios
A child who reacts to traces of allergen by skin contact, for example who reacts with anaphylaxis after grasping a door handle with traces of peanut protein on it will find it much harder to keep safe. This is a severe condition.
For more information see Various scenarios
In these cases anaphylaxis may occur for no obvious reason but the assumption is the child reacted to traces of food allergen in the environment. Such severe reactions to environmental contamination with allergens are very rare and should be supported by clear medical evidence from an allergy specialist. It should be clear that anaphylaxis has actually occurred, and not for example just a generalised rash. Alternative diagnoses such as idiopathic or exercise induced anaphylaxis also need to be ruled out. Children with extreme sensitivity will require meticulous attention to the contents of their diet like other children at risk. However they are likely to require more care and attention from parents because they are more at risk outside the home. For example a parent may need to accompany them on school trips to provide supervision to ensure avoidance and treatment in case of a reaction. Such a child might be home schooled because of their allergy.
Typical food preparation practice
Typically parents of children at risk of anaphylaxis will be very knowledgeable about their allergy, the foods that may contain the allergen, about food labelling regulations and food manufacturing methods. In order to avoid reactions families will often prepare most meals from scratch at home. This is the only way to ensure meals are not contaminated. Pre-prepared meals and sauces for home use or in catering often contain many different ingredients and unless clearly stated on the box there is always the possibility of contamination. A suitable item might list ‘prepared in a nut free facility’. Such labels are much less common than ‘may contain nuts’. A common problem when eating out for severely nut and fish allergic people is contamination of their food with traces of nut when their meal has been fried in oil previously used to fry nuts or fish. Often commercial food outlets will say they cannot guarantee any of the food is safe.
Families with allergic children are therefore less likely to eat out and less likely to allow their children to visit other people’s houses in the absence of a parent. In addition to keeping the home free of known allergenic foods and cooking from scratch, parents will often prepare safe food for their children to take with them when they visit friends and relatives or go to school. The time commitment per week is considerable. The time, care and attention paid to meals is fairly uniform across children at risk of anaphylaxis who have never reacted and children who have had severe reactions. Provision of safe food by parents is likely to continue until the child starts to take control of their own diet. At age 8 the child can be relied upon to understand the need to eat only safe food even when the parent is not there to remind them. If the child is allergic to multiple allergens time and care will be the same but providing a nutritious diet will be more challenging with limited ingredients.
Care required related to medication
Children at risk will be expected to follow the rule of eating only safe foods and only eating food when an adrenaline autoinjector is available. The parent or child will need to carry this with them at all times along with any other medication such as oral antihistamines. Carrying the adrenaline autoinjector is only a small part of the main care required. The main care is supervision to maintain allergen avoidance until the child is able to take on this role themselves.
