Expertise
I deal with all aspects of paediatric allergy and immuology and am committed to providing the best care to all of my patients.
Allergic diseases have become increasingly common, with 1 in 4 people in the UK suffering from allergy. There is often a clear progression of allergic symptoms with eczema and food allergy often being the first manifestation of allergic disease, followed by asthma and hayfever. This association of symptoms has been referred to as the allergic march.
As most of these allergic diseases are linked and develop in early infancy and childhood, a paediatric allergy specialist is ideally placed to care for these children, providing a holistic as well as longitudinal perspective to each child’s health care needs. Increasingly, the emphasis is shifting to early diagnosis, intervention and treatment.
Dr Helen Cox has considerable expertise in the diagnosis and management of eczema, urticaria, food allergy, anaphylaxis, asthma and hayfever. Her areas of specialist interest include managing the child with multi-system allergic disease who may have two or more of the above allergic conditions. She has considerable expertise in treating children with difficult eczema, helping to tease out the allergic and non-allergic factors that contribute to skin inflammation and is a well respected lecturer on the subject of "allergy and eczema" both within the UK and abroad.
She runs a busy food allergy service managing children who present with either immediate symptoms (nettle rash, facial swelling, anaphylaxis) or with more delayed presentations (ie colic, reflux, diarrhoea, constipation, failure to thrive). She has established links with several paediatric gastroenterologists in London and works closely with a superb team of paediatric dietitians, allergy nurses, speech and language therapists (for aversive feeding and swallowing difficulties) and clinical psychologists.
She is one of the few Paediatric Allergists offering injectable and sublingual immunotherapy to children with severe hayfever or venom allergy. Drug allergy testing is offered.
Allergic Rhinoconjunctivitis (Hayfever)
FACT SHEET
- Allergic rhinitis and allergic eye disease affects 25% of the UK population.
- Symptoms may be seasonal or perennial (all year round)
- Severity varies considerably from mild intermittent symptoms, which may be trivial, to severe daily symptoms with considerable impact on quality of life, sleep and daytime concentration.
- Symptoms are frequently under recognized and under treated
- Inadequately treated allergic rhinitis has been shown to influence academic performance with children at GCSE level been shown to drop a grade between their winter and summer exams when poorly controlled.
- Allergic rhinitis is frequently associated with asthma and can impact on asthma symptoms.
- Medical treatment is highly effective in controlling symptoms
- Immunotherapy can significantly alter the disease course with reduction in symptoms and need for medication.
WHAT TO EXPECT
A detailed clinical history will establish the severity and duration of symptoms and impact on quality of life.
Allergy tests (skin prick testing and/or specific IgE tests) will be carried out to define the allergens involved.
Lung function testing (Spirometry +/- Exhaled Nitric Oxide) may be done if asthma is suspected.
Advice on targeted allergen avoidance will be given
A written treatment plan will be provided.
Your child will be shown the correct technique for administering their nasal sprays and/or eye drops.
When appropriate, immunotherapy may be offered as a treatment option.
NOVEL THERAPIES
Immunotherapy is a highly effective treatment for severe allergic rhinitis when specific allergens are identified that are implicated in causing symptoms.
Treatment is available as either sublingual treatment (drops or tablets) or injectable treatment.
INFORMATION
The ARIA guidelines for Allergic Rhinitis
www.whiar.org
The BSACI guidelines for Allergic Rhinitis
www.bsaci.org/
The RCPCH care pathway for Asthma and Allergic Rhinitis (The united airway)
Care pathways for children with allergies
Asthma
FACTS
- Asthma affects 1 in 5 people in the UK
- Not all children who wheeze have asthma. It is important to identify other causes of cough and wheeze.
- Positive allergy tests to food and inhalant allergens increases the likelihood of asthma.
- Understanding the potential allergic triggers allows for targeted asthma treatment and improved asthma control
- In young infants persistent cough and wheeze may be secondary to gastro-oesophageal reflux.
- Allergic rhinitis (hayfever) is present in 50% of asthmatic children and can impact on asthma.
- Poorly controlled asthma is a major risk factor for anaphylaxis in children with known food allergy.
WHAT TO EXPECT
Children attending the allergy clinic will have a comprehensive history taken to evaluate possible causes of their symptoms.
Allergy testing (skin prick testing) will be undertaken where appropriate to identify possible allergic triggers.
Lung function testing using computerized spirometry and exhaled nitric oxide is carried out in children aged 6 years and above.
If required, blood testing will be done on the same day.
An individual treatment plan is provided based on the above clinical assessments, with treatment being tailored to each child’s specific needs
Advice on allergen avoidance is given
The allergy nurse in clinic will demonstrate your child’s asthma inhalers to ensure that these are being given correctly.
When appropriate, Dr Cox may discuss novel treatments for asthma with you.
NOVEL TREATMENTS FOR ASTHMA
Immunotherapy is increasingly being used for the treatment of chronic asthma. Specific immunotherapy to grass and tree pollen is highly effective in treating seasonal asthma ie asthma confined to the pollen season. Sublingual immunotherapy to house dust mite has been shown in several studies to be effective for treating asthma in patients with proven house dust mite allergy.
Airsonette laminated airflow device: This is a novel treatment with proven efficacy for treating asthma secondary to perennial inhalant allergies particularly house dust mite
www.airsonett.com
Xolair (Anti-IgE): This treatment is licensed for severe refractory asthma. Treatment is very expensive and therefore usually requires referral to an NHS tertiary asthma clinic, where treatment is justified based on measurable scores of disease outcome.
INFORMATION
British Thoracic Society Guideline for Asthma
www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
RCPCH care pathway for Asthma and Allergic Rhinitis
www.ncbi.nlm.nih.gov/pubmed/22053060
Itchysneezywheezy RCPCH care pathway for allergic diseases
www.itchysneezywheezy.co.uk
Asthma UK
www.asthma.org.uk
Eczema
FACT SHEET
- Affects 1 in 5 children
- 80% are sensitized to either food or inhalant allergens
- There is a direct correlation between eczema severity and food allergy.
- 30% to 65% of children with moderate to severe eczema are food allergic.
- Food allergy may cause immediate or delayed reactions in the skin and/or gut.
- The co-existence of eczema with gut symptoms (ie reflux, loose stools, constipation, abdominal pain, bloating) increases the risk of food allergy.
- 2/3 of children with eczema develop either asthma or allergic rhinitis
- Early detection of food and inhalant allergens allows for better understanding of the potential trigger factors for eczema and overall improvement in disease management
WHAT TO EXPECT
Children attending the clinic for eczema will have a detailed clinical history focusing on the possible trigger factors for their eczema and current use of creams and medications. Your child’s eczema will be scored in terms of severity and impact on quality of life.
As eczema frequently coexists with other allergic diseases (ie asthma, allergic gut disease), a multi-system approach is adopted to address the needs of the whole child.
Allergy testing will be carried out (skin prick testing and/or specific IgE testing).
Allergic and non-allergic trigger factors will be identified if present and advice given on allergen avoidance.
A comprehensive treatment plan will be given to ensure optimal treatment of the skin.
Where appropriate, referral to a paediatric dietitian will be offered to ensure that all diets are correctly structured and nutritionally sound.
INFORMATION LINKS
NICE GUIDELINE FOR ECZEMA:
www.nice.org.uk
This provides a helpful parents guideline to good eczema management
RCPCH CARE PATHWAYS FOR ECZEMA
Care pathways for children with allergies
This outlines the competencies needed to manage eczema and advice to healthcare professionals on when to refer.
Emollients, education and quality of life: the RCPCH care pathway for children with eczema. H Cox
www.ncbi.nlm.nih.gov/
ITCHYSNEEZY WHEEZY
This provides some very helpful information for parents including video links illustrating bathing, use of emollients and treatment creams
www.itchysneezywheezy.co.uk
NATIONAL ECZEMA SOCIETY
www.eczema.org
Food Allergies
FACT SHEET
- Food allergy affects 6-8% of children in the UK
- 2/3 of children with food allergy react to more than one food.
- The most common food allergens are cows milk, egg and nuts which account for 75% of all reactions.
- Other foods implicated include sesame, wheat, soya, kiwi, pulses, fish and shellfish.
- Reactions to foods may be immediate or delayed.
- Immediate reactions to foods cause a range of symptoms affecting the skin, gut and respiratory system. Allergy tests are usually positive.
- “Anaphylaxis” is the term used to describe a severe immediate reaction to food causing breathing difficulty or a drop in blood pressure.
- Delayed reactions to foods can cause eczema within 72 hours of food ingestion and/or reactions in the gut, leading to a range of symptoms including vomiting, reflux, abdominal pain, bloating, loose stools, constipation and faltering growth. Allergy tests are often negative and the diagnosis relies on the clinicians interpretation of the clinical history and signs.
- Correct identification of dietary allergens allows for avoidance and reduction or indeed resolution of symptoms.
- Unsupervised dietary avoidance in children can be dangerous, placing children at risk of vitamin and mineral deficiencies.
WHAT TO EXPECT
A thorough clinical history is essential to ensure the accurate diagnosis of food allergy. The clinical history will detail any possible immediate reactions to foods as well as delayed reactions to foods and the timing of food introductions.
Allergy testing will be carried out (skin prick testing and/or specific IgE testing). A diagnosis will be made based on combining the results of the allergy tests with the information obtained from the clinical history.
A personalized allergy management plan will be given detailing how to treat future food allergic reactions. Training in the use of an adrenaline autoinjector is an important part of the consultation if adrenaline is prescribed.
Bloods for nutritional testing (eg iron, vitamin D, calcium, zinc, selenium) will be requested if deemed appropriate.
Advice on dietary allergen avoidance will be given and a referral made to a paediatric dietitian. Comprehensive information will be provided by the dietitian on which foods to avoid and which to give.
Information will be provided on the likely natural history of your child’s food allergy based on their clinical history and test results.
INFORMATION
NICE guideline for food allergy
www.nice.org.uk/nicemedia/live/13348/53217/53217.pdf
RCPCH care pathways for food allergy
Care pathways for children with allergies
Anaphylaxis Campaign
www.anaphylaxis.org.uk
RCPCH care pathways for anaphylaxis
www.ncbi.nlm.nih.gov/pubmed/22053067
Food facts from the British dietetic Association
www.bda.uk.com/foodfacts
Immunotherapy
FACT SHEET
- Immunotherapy is the practice of administering gradually increasing doses of an allergen extract (eg pollen) in order to reduce the symptoms of hayfever or asthma that it causes.
- Immunotherapy modifies the immune response leading to a 40-60% reduction in symptoms and need for medication.
- The effect of treatment is sustained for many years after discontinuation of treatment. In this way it differs greatly from all other standard medications, which do not alter the course of allergic disease.
- Immunotherapy is available as injectable treatment (subcutaneous immunotherapy or SCIT) or as oral treatment in the form of drops or tablets (sublingual immunotherapy or SLIT)
SUBCUTANEOUS IMMUNOTHERAPY (SCIT)
Pre-seasonal treatment with injectable immunotherapy is currently offered to grass and tree pollen sufferers with severe seasonal symptoms. Treatment is typically initiated 3 months before the pollen season.
SCIT is very effective in the majority of patients, with a 20% reduction in symptoms in year one and a 40%-60% reduction in symptoms and need for medication by year three. Rarely, the treatment fails to reduce symptoms.
Pollinex Quattro is given as 4 injections administered 3-4 months pre-seasonally, given at 1-2 week intervals. The treatment cycle needs to be repeated each year prior to the pollen season. This treatment has the advantage of not relying on individual patient compliance.
Tree pollen SCIT is usually initiated in Dec – Jan. Grass pollen SCIT is usually initiated in Jan-Feb.
SUBLINGUAL IMMUNOTHERAPY (SLIT)
Sublingual immunotherapy (SLIT) entails the placing of drops or a soluble tablet under the tongue for 2 minutes. Therapy is initiated in clinic but then continued at home. Treatment is taken daily for the duration of the course. The total duration is for 3 years.
SLIT is highly effective treatment provided it is taken regularly, with a 40-60% reduction in symptoms and need for medication. The effect is noticed from year 1 of treatment.
Pre-seasonal treatment is initiated 2-3 months before the pollen season and continued for a further 3 months during the pollen season. This is repeated each year for 3 years.
Products currently available include:
Staloral drops for tree pollen - commenced Dec-Jan and given once daily x 6 months
Oralair tablets for grass pollen – commenced Feb-March and continued once daily x 6 months
Perennial treatment is given once daily or 3 x weekly for 3 years. Treatment is highly effective provided it is taken daily. Poor compliance with treatment will influence treatment outcomes.
Products available include:
Grazax tablets for grass pollen allergy
Staloral drops for house dust mite allergy.
Staloral drops for cat allergy
Urticaria
FACT SHEET
- Urticaria (hives) is a common skin manifestation of allergy. This is often associated with angioedema (swelling) of the face, hands, feet or genitalia. The reactions are usually short-lived subsiding within hours or 1-2 days of allergen exposure.
- Viruses can cause urticaria and angioedema and this is often mistaken for allergy. Viral triggered urticaria may persist for days, whilst the virus is in the body, but then subsides spontaneously.
- Urticaria can be more persistent and become chronic with skin lesions being present daily for 6 weeks or more. Chronic urticaria is rarely caused by an allergy. A circulating autoantibody is frequently present.
- Some persistent forms of urticaria are triggered by physical factors such as cold, water, sunshine, pressure or exercise.
WHAT TO EXPECT
A thorough clinical history will help identify the cause of your child’s urticaria in most cases.
Allergy testing may be required to confirm or refute allergy.
In chronic urticaria, blood tests need to be taken to check thyroid function and for the presence of circulating autoantibodies.
In cold urticaria, an ice cube challenge test will be carried out in clinic.
INFORMATION
BSACI guidelines on chronic urticaria
www.bsaci.org/guidelines/chronic-urticaria-and-angio-oedema
