Michel Erlewyn-Lajeunesse

Cow’s milk allergy (CMA) is one of the most common food allergies in infancy, with a prevalence of up to 7.5%. However, accurate diagnosis in primary care remains difficult due to overlapping symptoms with common infant behaviours and limited access to specialist allergy testing. Consequently, CMA is frequently over diagnosed, leading to unnecessary elimination diets, nutritional deficiencies, and increased parental anxiety. This paper introduces the EATERS-X framework, an enhanced, structured approach to obtaining an allergy-focused clinical history (AFCH) that aims to improve diagnostic precision and clinical decision-making in CMA. The tool expands upon the traditional EATERS method—comprising Environment, Allergen, Timing, Exposure, Reproducibility, and Symptoms—by incorporating an additional element, X, denoting treatment and healthcare response. Through clinical scenarios, we demonstrate how EATERS-X can be applied to distinguish between IgE-mediated, non-IgE-mediated, and mixed-type CMA, including subtypes such as food protein-induced enterocolitis syndrome (FPIES). While EATERS-X provides a practical and systematic framework for history-taking, its effectiveness is dependent on clinician training and appropriate clinical interpretation. In addition, the framework has not yet undergone formal validation against gold-standard diagnostic tests such as oral food challenges. Future prospective studies should evaluate the diagnostic reliability, inter-observer consistency, and clinical impact of EATERS-X across different healthcare settings. Integration of the EATERS-X approach in primary care aligns with current BSACI and EAACI guidelines and promotes structured, evidence-based, and patient-centred care. Future research should focus on validating the framework’s diagnostic reliability and exploring its applicability across a wider spectrum of allergic conditions.

Background: There is an unmet need for specialist allergy treatment in the United Kingdom. Allergen immunotherapy and treatment with omalizumab for chronic spontaneous urticaria (CSU) are key markers for these services. The British Society for Allergy and Clinical Immunology (BSACI) Registry for Immunotherapy (BRIT) is a national project to record the real‐world effectiveness, safety and access to treatment for aero‐allergen, venom and peanut immunotherapy as well as omalizumab for CSU. Methods: We described participant demographics, the index of multiple deprivation (IMD) and access to treatment from the registry launch. Data for 1835 participants were available for analysis from 63 centres enrolled between 1st October 2018 and 24th August 2023. Results: 96.5% (1771/1835) were living in England, with only 3.5% (64) being from the devolved nations. 14.4% (251/1748) were in the most affluent IMD decile compared to 4.5% (78/1748) in the most deprived IMD decile. White participants were 1.74 times more likely to be referred directly from primary care compared to people of Asian, black, mixed or other minority ethnic groups. Instead, these groups were referred more frequently from secondary or tertiary hospital services. The median distance travelled from home to the treatment centre was 15.2 miles, with evidence of clustering around specialist centres. Conclusions: We have described disparities and unwarranted variation in the provision of treatment around the UK. The data suggest that there is limited access to immunotherapy in the devolved nations. Access is also reduced by socioeconomic deprivation. White participants were more likely to receive a direct referral from primary care than those from other ethnic groups whose referral pathways were more complex. Registry data are limited by participant enrolment and may have selection bias. Nevertheless, BRIT has highlighted inequity in access to specialist allergy services in the UK.

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This guideline advises on the management of patients with egg allergy. Most commonly egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history will confirm the diagnosis in most cases. Investigation by measuring egg‐specific IgE (by skin prick testing or specific IgE assay) is useful in moderate‐severe cases or where there is diagnostic uncertainty. Following an acute allergic reaction, egg avoidance advice should be provided. Egg allergy usually resolves, and reintroduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive the MMR vaccine. Most adults and children with egg allergy can receive the influenza vaccine in primary care, unless they have had anaphylaxis to egg requiring intensive care support. Yellow Fever vaccines should only be considered in egg‐allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence based. Where evidence was lacking, consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co‐morbid associations.

Background Food protein-induced enterocolitis syndrome (FPIES) is a delayed type of food allergy, most often seen in infancy. We aimed to estimate its incidence, to describe common food triggers and the patient journeys of this rare but serious condition. Design We undertook a prospective epidemiological survey of FPIES using the British Paediatric Surveillance Unit. Setting UK and Ireland. Participants A survey of all paediatricians over 13 months between January 2019 and February 2020. Main outcome measures 204 cases were reported, 98 (48%) meeting case definition, giving an incidence of 0.006% for England based on 93 cases. Results 98 patients reported 135 trigger foods, 27% (26 of 98) had multiple food triggers. Common food triggers included cow’s milk (24%, 33 of 135), fruits and vegetables (19%, 26 of 135), hen’s egg (16%, 22 of 135) and fish (14%, 19 of 135). In 46% (41 of 90), the initial trigger food had been ingested three or more times before diagnosis, with a median diagnostic delay of 7.9 months (3.0, 17.3). Half (50 of 98) were admitted, yet only 5% (5 of 98) received appropriate acute treatment with ondansetron. Most cases were diagnosed by an allergy specialist (74 of 98, 76%), within a median of 7.5 (3.0, 13.3) miles from home. Conclusion The incidence of FPIES was significantly lower than expected across the whole of the British Isles. Most reports were of cases local to specialist allergy centres, with delays in diagnosis. This suggests under-recognition of FPIES in frontline clinical setting where education of healthcare professionals is required to improve recognition, earlier diagnosis and treatment.