IgE/Non-IgE and confusion

[louisabone]

I would really appreciate if you could cast your eye on my daughters case hopefully this wont be too long of a post

My daughter is 2, was diagnosed at 3 months with milk allergy and various other allergies.
The original diagnosis was given by a pead. after she turned failure to thrive, got rashes and it agrovated her reflux even when she had Nutramigen so she was put on Neocate and it solved the problem.

We then went for allergy testing and she had skin pricks done though she reacted to each one (though not the negitive control prick) it wasn't big enough for confirmation of allergy. so the dr gave us a diagnosis of Non-IgE allergy

When she was admited into hospital for an unrelated matter at 12ish months they forced me to give her Nutramigen again within 5 minutes of drinking it she became unsettled she then started passing wind and her eyes swelled... at this point she was screaming I was told it couldn't of been the Nutramigen because she tested negitive and eyes do not swell for foods.
I then discharged her myself and took her to sainsburys bought antihisthamine and gave it to her and the reaction began reversing 30 mins after i gave it to her

We then saw the dietion who agreed we were right to think it was the Nutramigen and told us to carry on, on the Neocate

She has had a few reactions to dairy now which have caused her eyes to swell, she went in a swing and her eye swelled so we think it was probabaly a touched where someone had split icecream (was summer) and touched her mouth

We keep being told that eye swells do not happen for non-IgE reactions though we take her when her eyes are swollen and we get no answers we know it happens when she accidently ingests dairy

Can this be non-IgE or is it probabaly really IgE? Can you get false negitive spt? (she was 6mthsish and we had obstained from antihisthamines for the 2 weeks like stated for them)
I don't know if anything comes to mind or anything

She is due to start Nursery this year and I am a disabled mum and I am at the point of trying to go private to get some answers (though we just cant afford it)

Thank you
Louisa

[Dr Helen Brough]

Dear Louisa,

I am sorry that you have had a lot of conflicting messages.

I am going to start by clarifying the difference between IgE and non IgE mediated allergy and how Allergists assess this. I wish to highlight that some children can have a mixed response (i.e. both IgE and non-IgE mediated allergies to the same food).

IgE mediated allergies classically present with urticaria (nettle rash), hives and swelling which may be associated with immediate vomiting, abdominal pain or loose stools, runny nose or eyes. This usually occurs within 30 minutes but certainly within 2 hours of eating the offending food. If severe, IgE mediated allergy (anaphylaxis) can present with breathing difficulties or becoming pale/lethargic. Allergists test for IgE mediated allergies with skin prick tests and specific IgE blood tests. Skin prick tests detect specific IgE bound to mast cells in the skin, which release histamine and other products and cause the wheal and flare when a small amount of the food protein is scratched beneath the surface of the skin. If the skin prick test is high (usually above 6mm) then we can predict that the child is likely to have an IgE mediated allergy to the food. If the skin prick tests are below 3mm but the child has a history of reacting to the food then the child may not be allergic, and we would then consider further tests or perform a diagnostic food challenge in hospital. If the skin prick test is between 3-6mm then this is a grey area and the child may be sensitised (i.e. a predisposition towards IgE mediated allergy) but not allergic and depending on the history we would either advise likely allergy or perform a diagnostic food challenge in hospital.

In non IgE mediated allergy symptoms usually present as a flare of eczema or gut symptoms, loose stools, pain, reflux usually 2 hours after eating the food. Skin prick tests are generally not helpful in this situation, as even if they are negative the food tested may still be driving the symptoms. If they are positive then they can give some clues though.

In the case of your daughter it seems that although she may have started with a non IgE mediated allergy to cow's milk with failure to thrive, gastroesophageal reflux and rashes (I presume eczema rashes not urticarial), after taking cow's milk out of the diet completely she then developed IgE mediated allergy to cow's milk; thus the immediate symptoms (swelling and gut symptoms) after Nutramigen and reactions to contact with cow's milk/dairy.

There is a published report in Allergy in 2006 of 47 infants who had cow's milk removed from their diet due to eczema and were then assess after a period of 1-8 years. When they were reassessed 15 children (32%) had negative allergy tests to cow's milk and were able to drink cow's milk without any problems, 21 children (45%) had positive allergy tests but were able to tolerate cow's milk (they had a hospital based challenge). Eleven children (23%) had positive allergy tests to cow's milk and had IgE mediated allergic reactions to cow's milk when they had a diagnostic food challenge in hospital.

I would recommend that you treat your daughter now as having an IgE mediated cow's milk allergy and avoid all forms of cow's milk and dairy in your daughter's diet. You should ensure you have an antihistamine available in case of an allergic reaction and at nursery. I would recommend you ask to be referred by your GP to an Allergist in the NHS. At this point your child can have repeat skin prick tests to cow's milk and the various other possible allergens you mentioned and be given an treatment plan for nursery.

Best wishes,

Dr Helen Brough

[louisabone]

Thank you very much for your time in looking over this, you're right it was originally eczema rashes which appeared on her face. and that certainly fits in with what our experiencewith her has been

You have certainly helped especially since you have made me feel like I'm doing things right, we do treat it as an IgE mediated atm because my gut feeling as a mum was telling me to do that (Though this is obviously not a trusted diagnostic tool)

We asked for a re-referral and heard nothing more so I will chase it up I was feeling a bit unsure if I should chase it and I definitely will now.

We were really last time just gone the wheals were less then 3mm non-IgE thats it never saw us again I think this time now if its the same I will ask for a food challenge now (since she is no longer going to be in our care 24/7)

[Dr Helen Brough]

Dear Louisa,

Thanks for your response. I agree depending on the results of the skin project tests it would be useful to have a diagnostic cow's milk challenge in hospital.

Best wishes,

Dr Helen Brough