SummaryThis guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age-and diseasespecific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance.

Background:The development of tolerance to cow's milk in allergic children is best determined by supervised baked milk exposure. Widely recommended hospitalbased challenges can potentially delay contact because of resource limitations. Objective:We sought to determine the efficacy and safety of our low-dose homebased reintroduction programme.Methods: In our allergy service, children with IgE-mediated cow's milk allergy who met set criteria (presenting with skin and/or gastrointestinal symptoms only and skin prick test < 8 mm) are considered for home-based milk reintroduction (HMR). Early contact is low-dose ingestion of a commercial baked milk biscuit with slow gradual further exposure followed by increasing milk contact using a milk ladder. We retrospectively reviewed 4-6 monthly attendance records assessing allergic symptoms, evolving milk tolerance, and compliance. Tolerance was determined using a 7 scale scoring system based on the milk ladder. Results:The clinic attendance and dietetic contact records of 86 children (49 girls) who underwent HMR were reviewed. HMR was started at a median of 13 months with 49% 8-12 months, 40% 13-18 months and 11% 19-33 months. Allergic symptoms were reported in 81 (43%) of 189 dietetic reviews, 65 (80%) of which were from the milk ladder; no patient experienced anaphylaxis requiring treatment with intramuscular adrenaline. After four reviews, only eight patients were not tolerating almost all dairy products, and there was a high rate of completion with only a further seven patients lost to the programme. Conclusion and Clinical Relevance:Cow's milk can be successfully and safely reintroduced in a cautious low-dose exclusively home-based programme in the appropriate clinical and family setting. K E Y W O R D Sfood allergy, pediatrics, quality-of-life

Children allergic to peanuts with negative allergy tests to tree nuts had no co-existing allergy, but were at risk of tree nut allergy where PTs were positive. Children with tree nut allergy were at risk of co-existing peanut or other tree nut allergy whether PTs were positive or negative. Oral challenges to clarify allergy status in all nuts show co-existing allergies even in young children and in so doing may reduce anxiety, minimize unnecessary dietary restrictions and prevent later episodes of anaphylaxis through uninformed exposure.

One in 50 children present with egg allergy. This is an update of the BSACI guideline for the management of egg allergy. 1 It was prepared by an expert group of the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and addresses the diagnosis and treatment of patients with egg allergy, for healthcare professionals working in secondary care. It includes guidance for families with egg-allergic children and adult egg-allergic patients. The guideline working group included paediatric and adult allergists, paediatric and adult allergy specialist dieticians and clinical psychologists working with egg-allergic patients. During development of this guideline, representatives from patient organizations (Allergy UK and Anaphylaxis Campaign) were part of the guideline writing group and involved in selection of topics, evidence, recommendations and draft reviews. Declarations of interest of the guideline lead and the writing group members are held at BSACI office and are available on request. None jeopardized unbiased guideline

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