\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Test-guided dietary advice for children with atopic dermatitis: a
consensus study}



\author[1]{Ludivine Garside}%
\author[2]{Robert Boyle}%
\author[3]{Rosan Meyer}%
\author[4]{Isabel Skypala}%
\author[3]{Hilary Allen}%
\author[5]{Paula Beattie}%
\author[6]{Justine Dempsey}%
\author[7]{Matt Doyle}%
\author[8]{Helen Evans-Howells}%
\author[9]{Mary Feeney}%
\author[10]{Sian Ludman}%
\author[11]{Tom Marrs}%
\author[12]{Jane Ravenscroft}%
\author[13]{Gary Stiefel}%
\author[14]{Thisanayagam Umasunthar}%
\author[15]{Deepan Vyas}%
\author[16]{Natalie Yerlett}%
\author[17]{Jo Walsh}%
\author[18]{Sara Brown}%
\author[1]{Matthew Ridd}%
\affil[1]{University of Bristol}%
\affil[2]{Imperial College London National Heart and Lung Institute}%
\affil[3]{Imperial College London}%
\affil[4]{Royal Brompton and Harefield Hospitals}%
\affil[5]{Royal Hospital for Children}%
\affil[6]{Imperial College Healthcare NHS Trust}%
\affil[7]{Jersey Allergy Clinic}%
\affil[8]{Dr Helen Allergy}%
\affil[9]{King's College London}%
\affil[10]{Royal Devon University Healthcare NHS Foundation Trust}%
\affil[11]{Guy's and St Thomas' NHS Foundation Trust}%
\affil[12]{Nottingham University Hospitals NHS Trust}%
\affil[13]{University Hospitals of Leicester NHS Trust}%
\affil[14]{Oxford University Hospitals NHS Foundation Trust}%
\affil[15]{West Hertfordshire Teaching Hospitals NHS Trust}%
\affil[16]{Great Ormond Street Hospital for Children NHS Foundation Trust}%
\affil[17]{Castle Partnership}%
\affil[18]{The University of Edinburgh}%


\vspace{-1em}



  
  \date{May 21, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Background: The use of allergy tests to guide dietary exclusions for
disease control in children with atopic dermatitis (AD) is
controversial. We undertook a consensus exercise on how to interpret
skin prick test (SPT) results and dietary history for cow's milk, hen's
egg, wheat and soya in children \textless{}2 years old with AD. Methods:
Fourteen clinicians from general practice, paediatrics, paediatric
dermatology, paediatric allergy and paediatric dietetics from UK and
Ireland took part in an online modified Delphi study. Over three rounds,
participants gave their anonymous opinions and received individualised
and group feedback. The findings were discussed in an online workshop.
Results: Of 14 symptoms, 12 were identified as relevant to immediate and
7 to delayed allergy. Regarding SPTs, there was consensus over which
allergens to use for wheat and soya but not cow's milk or hen's egg; for
all study foods, wheal size was determined as 0-1 mm negative, [?]5mm
sensitised , but between 2-4 mm categorisation varied by food. During
the final workshop, consensus was reached on dietary advice should be
given according to SPT results and dietary history. Conclusion: We
attained consensus on how SPTs combined with dietary history for four
common food allergens should be interpreted in young children under two
years of age with AD. These pragmatic recommendations may support
clinician education, consistency of decision-making and future research.%
\end{abstract}%



\sloppy


\section*{Title page}

{\label{title-page}}

\subsection*{Title}

{\label{title}}

Test-guided dietary advice for children with atopic dermatitis: a
consensus study

Characters (including spaces): 81/100

\subsection*{Short Title}

{\label{short-title}}

Test-guided dietary advice in childhood eczema

Characters (including spaces): 46/100

\subsection*{Authors}

{\label{authors}}

Ludivine Garside, Robert Boyle, Rosan Meyer, Isabel Skypala, Hilary
Allen, Paula Beattie, Justine Dempsey, Matt Doyle, Helen Evans-Howells,
Mary Feeney, Si\selectlanguage{ngerman}ân Ludman, Tom Marrs, Jane Ravenscroft, Gary Stiefel,
Thisanayagam Umasunthar, Deepan Vyas, Natalie Yerlett, Jo Walsh, Sara J
Brown, Matthew J Ridd

\subsection*{Affiliations of authors}

{\label{affiliations-of-authors}}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Title} & \textbf{Authors} & \textbf{Institution} & \textbf{ORCID
ID}\tabularnewline
\midrule
\endhead
Dr & Ludivine Garside & University of Bristol &
0000-0003-0560-0294\tabularnewline
Dr & Robert Boyle & National Heart and Lung Institute, Imperial College
London & 0000-0002-4913-7580\tabularnewline
Dr & Rosan Meyer & Imperial College, London, Winchester University, KU
Leuven & 0000-0002-5710-5570\tabularnewline
Dr & Isabel Skypala & Royal Brompton \& Harefield Hospitals, part of
Guys and St Thomas NHS Foundation Trust &
0000-0003-3629-4293\tabularnewline
Dr & Hilary Allen & Imperial College London, UK &
0000-0002-7013-0308\tabularnewline
Dr & Paula Beattie & Royal Hospital for Children, Glasgow &
n.a.\tabularnewline
Mrs & Justine Dempsey & Imperial College Healthcare NHS Trust &
n.a.\tabularnewline
Dr & Matt Doyle & Jersey Allergy Clinic, St Lawrence, Jersey &
n.a.\tabularnewline
Dr & Helen Evans-Howells & Dr Helen Allergy, Bournemouth &
n.a.\tabularnewline
Ms & Mary Feeney & King's College London &
0000-0003-0594-7052\tabularnewline
Dr & Si\selectlanguage{ngerman}ân Ludman & Royal Devon University Healthcare NHS Foundation
Trust & 0000-0003-3622-4957\tabularnewline
Dr & Tom Marrs & Guy's and St Thomas' NHS Foundation Trust &
0000-0003-2865-0606\tabularnewline
Dr & Jane Ravenscroft & Nottingham University Hospitals NHS Trust &
0000-0002-1609-7084\tabularnewline
Dr & Gary Stiefel & University Hospitals of Leicester NHS Trust &
n.a.\tabularnewline
Dr & Thisanayagam Umasunthar & Oxford University Hospitals NHS
Foundation Trust & n.a.\tabularnewline
Dr & Deepan Vyas & West Hertfordshire Hospitals NHS Trust &
0000-0001-7541-9904\tabularnewline
Mrs & Natalie Yerlett & Great Ormond Street Hospital for Children NHS
Foundation Trust & 0000-0001-6058-0682\tabularnewline
Dr & Joanne Walsh & Castle Partnership, Norwich & n.a.\tabularnewline
Prof & Sara Brown & University of Edinburgh &
0000-0002-3232-5251\tabularnewline
Prof & Matthew Ridd & University of Bristol &
0000-0002-7954-8823\tabularnewline
\bottomrule
\end{longtable}

\subsection*{Word count}

{\label{word-count}}

3145/3500 (excluding abstract, figure legends and references)

\subsection*{Number of tables/figures (max
6)}

{\label{number-of-tablesfigures-max-6}}

3 tables and 1 figure (supplementary 3 tables, 2 figures)

\subsection*{Author contributions}

{\label{author-contributions}}

MJR conceived the idea and secured funding for the project with SJB. The
project was led by MJR, delivered by LG, with support from SJB, RB, RM
and IS. MJR/SJB/RB/RM/IS/LG recruited the panel. LG/MJR co-led on data
acquisition (survey design, piloting and administration), analysis and
interpretation, and drafted the manuscript. SJB/RB/RM/IS contributed to
survey design and piloting, data analysis and interpretation via
discussions during regular research meetings. HA, PB, JD, MD, HE-H, MF,
SL, TM, JR, GS, TU, DV, NY and JW were members of the panel. All authors
contributed to interpretation of the data and to critical revision of
the manuscript for important intellectual content.

\subsection*{Acknowledgements}

{\label{acknowledgements}}

This study was funded by a joint award from the Rosetrees Trust and The
Stoneygate Trust (OoR2021\textbackslash{}100007), and supported by BNSSG
ICB. Sara Brown is a Wellcome Trust Senior Research Fellow
(220875/Z/20/Z).

The research team are grateful to Professor Miriam Santer, University of
Southampton, for chairing the workshop.

\emph{Conflict of interest}

JW has sat on clinical advisory panels to Allergy UK and Anaphylaxis UK.
GS acts as Trustee to Allergy UK, contributed to an educational video on
atopic dermatitis with Sanofi and is Principal Investigator for NARF
study. RM is on the advisory panel of CoMISS supported by Nestle Health
Science, has provided consultancy to Else Nutrition, and received
honoraria for lectures from Nutricia/Danone, Abbott, and Reckitt
Benckiser. IS has received honoraria honoraria for lectures from
ThermoFisher, Royal College of GPs, TouchiME. MJR is chief investigator
on the Trial of IgE food allergy tests for Eczema Relief (TIGER) study.

\subsection*{Ethical statement}

{\label{ethical-statement}}

The study was reviewed and approved by the University of Bristol Faculty
of Health Science Research Ethics Committee (reference 10819).

\section*{Abstract}

{\label{abstract}}

Background: The use of allergy tests to guide dietary exclusions for
disease control in children with atopic dermatitis (AD) is
controversial. We undertook a consensus exercise on how to interpret
skin prick test (SPT) results and dietary history for cow's milk, hen's
egg, wheat and soya in children \textless{}2 years old with AD.

Methods: Fourteen clinicians from general practice, paediatrics,
paediatric dermatology, paediatric allergy and paediatric dietetics from
UK and Ireland took part in an online modified Delphi study. Over three
rounds, participants gave their anonymous opinions and received
individualised and group feedback. The findings were discussed in an
online workshop.

Results: Of 14 symptoms, 12 were identified as relevant to immediate and
7 to delayed allergy. Regarding SPTs, there was consensus over which
allergens to use for wheat and soya but not cow's milk or hen's egg; for
all study foods, wheal size was determined as 0-1 mm negative, [?]5mm
sensitised , but between 2-4 mm categorisation varied by food. During
the final workshop, consensus was reached on dietary advice should be
given according to SPT results and dietary history.

Conclusion: We attained consensus on how SPTs combined with dietary
history for four common food allergens should be interpreted in young
children under two years of age with AD. These pragmatic recommendations
may support clinician education, consistency of decision-making and
future research.

Words: 223/250

\section*{Keywords}

{\label{keywords}}

Atopic dermatitis, consensus, diet therapy, food hypersensitivity, skin
tests.

\section*{Research Highlights}

{\label{research-highlights}}

\begin{itemize}
\tightlist
\item
  We conducted an online consensus exercise with a multidisciplinary
  clinical panel expert in childhood atopic dermatitis (AD) and/or food
  allergies management.
\item
  We developed a dietary advice tool to interpret dietary history and
  skin tests for 4 foods in children under two with AD.
\item
  While parents may seek testing to guide dietary exclusion, the tool
  also guides introduction, reintroduction and inclusion.
\end{itemize}

Words: 60/60

\section*{Introduction}

{\label{introduction}}

Atopic eczema/atopic dermatitis (AD) has a high disease burden and
affects around 20\% of children.{[}1{]} Most children with AD have
mild-moderate disease and can be managed with a combination of
emollients and anti-inflammatory treatments, usually topical
corticosteroids (TCS). However, topical therapies can be messy and time
consuming, and parents commonly worry about their safety.{[}2{]} This,
combined with the perception that AD creams only treat the symptoms
leads many carers to modify their child's diet or seek food allergy
tests, in the belief that this will identify an underlying dietary
cause.

The association between AD, food sensitisation and food allergy is
recognised.{[}3{]} Up to half of children with AD are ``sensitised'' on
blood IgE or skin prick tests to specific foods, without necessarily
having any clinical symptoms. The prevalence of food allergy is highest
0--2 years (39.2\%) and is associated with early onset and more severe
disease.{[}4{]} Cow's milk, hen's egg, wheat and soya are four of the
foods that commonly cause food allergy, raise concern about food allergy
among parents, and/or are excluded without professional advice.{[}5,
6{]} They are also some of the most challenging foods to attribute to
delayed, non-IgE mediated allergy symptoms and to exclude from the diet.

When there is an immediate reaction to these foods, the causal link may
be obvious, but parents of children with AD also worry about delayed
food allergy, and a food-related worsening of AD. In clinical settings,
symptoms usually determine whether a food allergy test is done. However,
sometimes clinicians use food allergy tests, in the absence of a
relevant allergy symptoms, to guide dietary advice for children with
AD.{[}7{]} The evidence to support this approach is weak.{[}8{]}

To support further research in this area, and to inform clinical
practice meanwhile, we conducted a consensus exercise on how symptoms
and skin prick test results should be interpreted to guide dietary
advice in children with AD.

\section*{Methods}

{\label{methods}}

\subsection*{Study design}

{\label{study-design}}

We undertook an modified version of the Delphi consensus method,{[}9{]}
which is a way to structure a group to communicate about and deal with a
complex problem, ``based on the idea that it is possible and valuable to
reach a consensus.''{[}10{]} It is particularly useful in areas of
limited research and is suited to explore areas where controversy,
debate or a lack of clarity exist. We have conducted and report this
work in line with the conducting and REporting DElphi Studies (CREDES)
guidance.{[}11{]}

The exercise, carried out over 11-weeks between June and September 2022,
comprised three anonymous survey rounds and a final online workshop. The
aim was to reach agreement on relevant allergy symptoms, SPT allergens
and thresholds, and what dietary advice should be given, based on a
given combination of symptoms and SPT results for four foods: cow's
milk, hen's egg, wheat, soya.

\subsection*{Recruitment of panel
members}

{\label{recruitment-of-panel-members}}

The research team identified five relevant professional groups
(allergists, dermatologists, dietitians, general practitioners with an
interest in allergy, and paediatricians) and sought to recruit at least
two panel members from each group, from varied geographical settings.
Potential participants were approached through professional networks.

From 22 experts approached in May/June 2022, 19 expressed of interest,
with 14 able to participate. Panel members provided consent and data on
personal/professional characteristics. In recognition of the time
commitment, participants were offered \selectlanguage{ngerman}£50 for each of the three surveys
and consensus meeting, with an additional payment of £50 for engaging
with all four events.

\subsection*{Consensus process}

{\label{consensus-process}}

Following the Delphi approach, panellists remained anonymous in the
survey rounds. All surveys were completed online and after every round
each panellist received a personalised summary detailing their own
answers and the anonymised answers aggregated across the entire panel.
The summaries confirmed where agreement had been reached, and previewed
items to be revisited at the next round. The majority of survey items
asked for opinions rather than whether the participant agreed or
disagreed with a statement, and free text responses were invited, to
allow respondent to explain their responses or to raise any issues.

Comments and suggestions by panel members were used to modify or add new
survey items for subsequent rounds. For example, between rounds one and
two, some symptoms were reworded or split into two symptoms. Items in
rounds one and two that were new, had been substantially modified or
with insufficient agreement were carried forward to the subsequent round
(Table S1). Therefore, only those items which were unchanged and with
consensus were removed between rounds.

Delphi studies require criteria for consensus to be clearly
defined\emph{a priori,} including the threshold for agreement. We sought
agreement of 80\% or above. Items with agreement below 80\% were carried
through to the next round or discussed at the workshop.

\subsection*{Online rounds}

{\label{online-rounds}}

All surveys were first drafted offline, transferred onto
onlinesurveys.ac.uk, and tested before release. Once live, the first
respondent to the round two survey raised the absence of their preferred
answer option to one of the questions. Their answer was noted for
analysis, and this option added before the remaining panellists
completed the survey.

Each survey was open for a minimum of two weeks. Panellists were asked
to answer the survey questions in the context of a child less than two
years old with mild, moderate or severe AD and no recorded allergy to
the study foods.

Round one asked which symptoms (timing and type) should be considered as
immediate- and/or delayed-type food allergy, which SPT reagents were
most appropriate for the four study foods, and how the SPT results
should be interpreted (Table S1). Round two asked respondents what
dietary advice should be given according to 72 possible combinations of:
immediate, delayed or no allergy symptoms; had or had not recently
ingested the food; and negative, equivocal or positive skin prick tests
(Table S1). The results were summarised for round three distinguishing
only between ``negative'' and ``positive'' SPTs (no equivocal category).
In round three, participants were also asked their opinion when a child
had never ingested the food.

\subsection*{Workshop}

{\label{workshop}}

The workshop aimed to reach consensus on areas where there was
insufficient agreement and to pull the findings together in a dietary
advice flowchart. It took place online in September 2022, lasted 1.5
hours, and was chaired by an academic general practitioner with an
interest in dermatology, who was independent of the process. Minutes of
the discussion and the final flowchart were circulated to all panel
members and approved post-workshop.

\subsection*{Analysis}

{\label{analysis}}

Data were exported from the online survey website and analysed using
Stata (version 17.0). Free text comments were collated under themes by
LG and reviewed by the research team (LG, MJR, RB, RM, IS and SJB).

\subsection*{Measures to prevent bias}

{\label{measures-to-prevent-bias}}

To ensure there was critical reflection of outcomes within the team, the
process leads (LG, primary care researcher from a quantitative social
sciences background, and MJR, academic general practitioner with a
research interest in skin and allergy) met monthly with the steering
group (all clinical academics -- RB paediatric consultant allergist, SJB
consultant dermatologist, and RM and IS, dietitians).

All panel members were invited to be co-authors, to credit their
intellectual contribution and to represent diversity of opinion.

\subsection*{Ethics}

{\label{ethics}}

The study was reviewed and approved by the University of Bristol Faculty
of Health Science Research Ethics Committee (reference 10819).

\subsection*{Funding}

{\label{funding}}

This study was funded by a joint award from the Rosetrees Trust and The
Stoneygate Trust (OoR2021\textbackslash{}100007), who had no input into
design, delivery, analysis or reporting.

\section*{Results}

{\label{results}}

\subsection*{Participation}

{\label{participation}}

The panel of 14 members (Table 1) comprised 11 doctors (seven
specialists and four GPs with an interest in allergy) and three
paediatric dietitians; nine were female. The mean age was 46.7 years (SD
5.4, range 40 to 57). Most (11) worked in England, with one each from
Jersey, Scotland, and the Republic of Ireland.

Response rates to the three survey rounds were 100\%, 93\% and 100\%
respectively. One partial round 2 response, saved and not submitted due
to lack of time, was excluded after discussion with the panel member.
Two panellists were unable to attend the workshop.

\subsection*{Clinical symptoms}

{\label{clinical-symptoms}}

The results for rounds one and two, and the final agreed list, around
which symptoms/timescales are indicative of an immediate (IgE) or
delayed (non-IgE) allergic reaction are shown in Table 2.

In round one, opinions were sought on the 14 skin, gut or airways
symptoms. Of these, consensus emerged on 12 immediate and 12 delayed
allergy symptoms/timescales.

For round two, ``abdominal pain/bloating, including `colic''' was
reworded to ``abdominal pain''; ``Noisy or difficulty breathing'' was
replaced by ``Hoarse voice or cry'' and ``Swelling of tongue or
airway/stridor''; and for delayed only, ``Rash, redness of skin''
replaced by ``Rough or bumpy, itchy skin'' and ``New eczema flare''.
After round two, there was no consensus for two symptoms: ``Nasal
congestion or runny nose'' for immediate and delayed allergy; and
``Rough or bumpy, itchy skin'' for delayed allergy.

Allergy symptoms were not discussed further at the workshop but it was
agreed in this write-up to reword ``Rash, redness of skin'', accepted at
round one as an immediate symptom, to ``Worsening of eczema (new
flare)'', to be consistent with delayed, and more appropriate for
non-white skin. The final list comprises 12 immediate and 7 delayed
allergy symptoms (Table S3).

\subsection*{SPT allergens}

{\label{spt-allergens}}

In round one, the panel had a choice of specific foods, commercial
reagents or other. Consensus was reached at round one (Table S2) for
wheat (commercial wheat extract, 86\%) and at round two for soya
(commercial soya extract, 83\%). There was consensus at round one for
egg (commercial extract, 86\%) but no further consensus between
commercial whole egg extract and commercial egg white extract (Table S2)
in round two. There was no consensus for milk.

\subsection*{SPT thresholds}

{\label{spt-thresholds}}

For each food, the panel were asked to interpret wheal sizes ranging
from 0 to 9 mm as negative, equivocal or positive. There was consensus
for all study foods for 0-1 mm being negative and 5 mm and above as
positive (Table 3). Uncertainties remained in the 2-4 mm range, with
varying levels of consensus depending on the food.

\subsection*{Dietary advice}

{\label{dietary-advice}}

The dietary advice findings from round two were presented to
participants pictorially, as a flowchart. This depicted the dietary
advice considered most appropriate for the 12 different possible
combinations (``scenarios'') of symptoms (ingested recently -- yes/no;
symptoms -- none, immediate or delayed) and SPT results (negative or
positive) (figure S1) for a child who had previously ingested the food.
For each scenario, the advice could vary by study food. There was
consensus across all foods in five scenarios (e.g. SPT -- negative,
ingested recently -- yes, symptoms -- none = not allergic, include); no
consensus for any food in three scenarios (e.g. SPT -- positive,
ingested recently -- no; symptoms -- delayed); and consensus for some
but not all foods in the remaining four scenarios.

The seven scenarios where there was disagreement for one or more foods
were carried forward into round three. Two additional scenarios were
introduced into round three, for a child who had never previously
ingested the study food and whose SPT was negative or positive. The
combined findings from rounds two and three are presented in figure S2.
There was consensus on 39 (70\%) of the 56 possible food scenarios:
consensus across all foods in seven (50\%) scenarios, partial consensus
in five (36\%) scenarios and no consensus for any food in two (14\%)
scenarios.

All scenarios were reviewed in the workshop but discussion focused on,
and resolved, all the areas of prior disagreement, with the resulting
flow chart shown in Figure 1. Based on feedback, ``positive'' SPTs were
relabelled as ``sensitised''.

\section*{Discussion}

{\label{discussion}}

\subsection*{Summary}

{\label{summary}}

We present a flowchart to aid the interpretation of dietary history and
skin prick test results from children with AD less than two years of
age. This tool is based on a consensus exercise with a
multi-disciplinary panel of clinicians with expertise in the management
of children with AD and/or food allergies. It is underpinned by advice
on which 12 or 7 symptoms to consider relevant to possible immediate or
delayed allergy respectively and which skin prick test thresholds to
regard as negative or sensitised. Consensus was reached for the use of
commercial reagents for wheat and soya but not which specific regents to
use for milk or egg skin prick tests.

\subsection*{Strengths and limitations}

{\label{strengths-and-limitations}}

This is the first published attempt to use a formal consensus process to
agree what dietary advice should be given to parent of children with AD
based a given combination of dietary symptoms and skin prick tests
results to four foods, which are commonly allergenic or are suspected by
parents as causing their child's AD symptoms. The exercise benefitted
from with perspective of clinicians from different disciplines, working
in generalist and specialist care. Panellist engagement was high, frank
views were shared and anonymity was retained until the workshop.

A consensus exercise has recently been undertaken to address
uncertainties with the detection and management of milk allergy in
children under two years of age.{[}12{]} Modifications to the Delphi
process are not an isolated practice in the health sciences{[}13{]} and
were necessary for the sake of brevity.{[}14{]} The online format
allowed the panel to be drawn from across the UK, so findings could
reflect practice variations which may exist between regions and
populations being served, and support the panel member commitment to the
whole process. The short timescale over which the consensus exercise was
conducted may have helped recall of previous rounds and maintained
engagement.

Nevertheless, the findings will not apply to all young children with AD
and opinions outside of the 14 panel members and the UK may be more
varied. It is also possible that had all panellists been able to engage
with all stages, the findings may been different. Although participants
were proficient at contributing and exchanging views online, persuasive
arguments may have been made or received differently in a face-to-face
meeting. Skin prick tests for milk and egg are more reliable than wheat
or soya and these results do not directly correlate with specific IgE
levels from blood tests. Although decision-making about food allergy
testing and subsequent dietary modifications should be shared and
discussed with parents and carers in a clinical consultation, because of
its technical nature patients representatives were not involved in this
process. However, the findings do begin to address the research
priorities identified by patients, carers and clinicians of ``What role
might food allergy tests play in treating eczema?'' and ``What is the
role of diet in treating eczema: exclusion diets and nutritional
supplements?''{[}15{]}

The complexity of food allergy in children is such that it can be argued
that decision-making cannot be protocolised.{[}16{]} Allergy history
taking takes time, expertise and can be a subtle art, where through
careful conversation, concerns or symptoms can be identified as relevant
or reassurance given. This is particularly the case with severe AD of
early onset, certain symptom complexes (e.g. co-occurrence of skin and
gut symptoms), when multiple foods are implicated and/or there is a
prior food allergy diagnosis. Similarly, evidence of impact on the
growth and/or micronutrient deficiency trajectory of a child are
important considerations.{[}17{]} Although treatment plans can be
decided and advised with multidisciplinary support, their implementation
and maintenance relies on parents/carers understanding and ability to
adhere to them for the long-term. In the absence of any benefits
outweighing potential harms from routine food allergy to guide dietary
advice for the management of AD,{[}8{]} parents should still be
supported to use topical therapies to treat their child's skin.

In consensus exercises, the context in which questions are presented is
important.{[}14{]} The same questions presented in another setting may
have elicited different responses. The context for this exercise, where
skin prick tests are performed on ``all-comers'', departs from usual
clinical practice where symptoms are usually assessed first to determine
the merit of food allergy tests. It also assumes that for any child who
needs it, oral food challenges~will be done in a timely manner,
something which currently does not happen in the UK, for example.
Finally, it also supposes that parents and carers of trial children will
be supported to safely exclude or reintroduction of study food(s) as
appropriate.

\subsection*{Findings in the context of the
literature}

{\label{findings-in-the-context-of-the-literature}}

Dietary modification by parents of children with AD, seeking to reduce
symptoms, is common and often without any healthcare input.{[}6{]}
Undiagnosed delayed food allergy as the cause for AD symptoms and the
use of blood specific IgE or skin prick food allergy tests to guide
dietary advice is controversial. Clinical opinions are divided with
healthcare professionals but those working in allergy and paediatrics
are more likely to request a food allergy test than those working in
dermatology or primary care.{[}7, 18{]} Mortz et al have published an
algorithm (based on ``expert opinion and available literature'') on
``When and how to evaluate for immediate (IgE\selectlanguage{english}-mediated) food allergy in
children with atopic dermatitis''.{[}19{]} This similarly recommends
that a careful dietary history and an assessment of AD severity is
obtained prior to any allergen testing. Consequently, decision making
for children with no symptoms, immediate symptoms and/or moderate-severe
AD is relatively straightforward. On-going research, based on our
findings, will help to address the gap where there are parental concerns
in a child with mild AD and/or possible delayed symptoms.{[}20{]}

A recent systematic review of 10 RCTs concluded that dietary elimination
``may lead to a slight, potentially unimportant improvement in AD
severity, pruritus, and sleeplessness'' in patients with mild to
moderate AD.{[}8{]} However, only four of the included studies had
interventions based on positive allergy tests, oral food challenges, or
both.{[}21-24{]} There was limited data on potential harms from such
interventions and as the authors point out, any potential benefits must
be balanced against the psychosocial impact of food exclusion,
developmental and nutritional problems and indeed the risk of developing
IgE-mediated food allergy.{[}25{]}

\subsection*{Implications for research, policymakers or
clinicians}

{\label{implications-for-research-policymakers-or-clinicians}}

Until further research clarifies the relationship between food allergy
and AD, and the role of food allergy tests, use of IgE food allergy
tests in clinical settings should continue be confined to help confirm
or refute the diagnosis of immediate-type allergies, following an
allergy focused history.{[}18{]} Clinicians need to be mindful that
parental concerns about food allergy and modifications to the diets of
children with AD is under-recognised and a dissonance can exist between
parental and clinicians views.{[}26{]} Regardless of opinions about food
allergy testing, clinicians should seek to identify and address these
issues as they can be a barrier to effective use of topical treatments
and have consequences for nutrition and diet quality.

Although food allergy testing may be sought by parents of children with
AD to guide dietary exclusions, the findings from this exercise can also
guide introduction, reintroduction and inclusion of foods where parents
are unsure based on symptoms, or have misplaced concerns which are
addressed by a negative skin prick test result.

\section*{Conclusion}

{\label{conclusion}}

The relationship between AD and food allergy is complex, and food
allergy tests are imperfect. The findings from this consensus exercise
will help support clinician education, consistency of decision-making
and future research.

\section*{References}

{\label{references}}

{[}1{]} Laughter MR, Maymone MB, Mashayekhi S, Arents BW, Karimkhani C,
Langan SM, Dellavalle RP, Flohr C. The global burden of atopic
dermatitis: lessons from the Global Burden of Disease Study 1990--2017.
British Journal of Dermatology. 2021 Feb; 184(2):304-9.
Doi:\emph{10.1111/bjd.19580}

{[}2{]} Teasdale E, Muller I, Sivyer K, Ghio D, Greenwell K, Wilczynska
S, Roberts A, Ridd MJ, Francis N, Yardley L and Thomas KS. Views and
experiences of managing eczema: systematic review and thematic synthesis
of qualitative studies.~British Journal of Dermatology,~2021 Apr 1;
184(4): 627-637. Doi:\emph{10.1111/bjd.19299}

{[}3{]} Tsakok T, Marrs T, Mohsin M, Baron S, du Toit G, Till S, Flohr
C. Does atopic dermatitis cause food allergy? A systematic review.
Journal of Allergy and Clinical Immunology. 2016 Apr 1;
137(4):1071-1078. Doi:

\emph{10.1016/j.jaci.2015.10.049}

{[}4{]} Christensen MO, Barakji YA, Loft N, Khatib CM, Egeberg A,
Thomsen SF, Silverberg JI, Flohr C, Maul JT, Schmid\selectlanguage{english}-Grendelmeier P,
Halling AS. Prevalence of and association between atopic dermatitis and
food sensitivity, food allergy and challenge\selectlanguage{english}-proven food allergy: A
systematic review and meta\selectlanguage{english}-analysis. Journal of the European Academy of
Dermatology and Venereology. 2023 May; 37(5):984-1003.
Doi:\emph{10.1111/jdv.18919}

{[}5{]} Hon KLE, Leung TF, Kam WYC, Lam MCA, Fok TF, Ng PC. Dietary
restriction and supplementation in children with atopic
eczema.\emph{Clinical and Experimental Dermatology.} 2006; 31(2):187-91.
Doi:\emph{10.1111/j.1365-2230.2005.02002.x}

{[}6{]} Chan J, Ridd MJ. Beliefs and practices among adults with eczema
and carers of children with eczema regarding the role of food allergy.
Clinical and Experimental Dermatology. 2019; 44(7):e235-e237.
Doi:~\emph{10.1111/ced.13955}

{[}7{]} Gilbertson A, Boyle RJ, MacNeill S, Ridd MJ. Healthcare
professionals' beliefs and practices regarding food allergy testing for
children with eczema. Clinical \& Experimental Allergy. 2021;
51(5):735-739. Doi:\emph{10.1111/cea.13859}

{[}8{]} Oykhman P, Dookie J, Al-Rammahy H, de Benedetto A, Asiniwasis
RN, LeBovidge J, Wang J, Ong PY, Lio P, Gutierrez A, Capozza K. Dietary
elimination for the treatment of atopic dermatitis: a systematic review
and meta-analysis. The Journal of Allergy and Clinical Immunology: In
Practice. 2022 Oct 1; 10(10):2657-66.
Doi:\emph{10.1016/j.jaip.2022.06.044}

{[}9{]} Nasa P, Jain R, Juneja D. Delphi methodology in healthcare
research: how to decide its appropriateness. World Journal of
Methodology. 2021 Jul 7;11(4):116. Doi:\emph{10.5662\%2Fwjm.v11.i4.116}

{[}10{]} Iqbal S, Pipon-Young L. The Delphi method with a step-by-step
guide. The Psychologist. 2009 Jul;
22(7):598-601.\emph{https://www.bps.org.uk/psychologist/delphi-method}

{[}11{]} Junger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance
on Conducting and Reporting Delphi Studies (CREDES) in palliative care:
Recommendations based on a methodological systematic review.~Palliative
medicine. 2017;~31(8): 684-706. Doi:\emph{10.1177/0269216317690685}

{[}12{]} Allen HI, Pendower U, Santer M, Groetch M, Cohen M, Murch SH,
Williams HC, Munblit D, Katz Y, Gupta N, Adil S. Detection and
management of milk allergy: Delphi consensus study.~Clinical \&
Experimental Allergy. 2022; \emph{52} (7): 848-858.
Doi:\emph{10.1111/cea.14179}

{[}13{]} Niederberger M, Spranger J. Delphi technique in health
sciences: a map. Frontiers in public health. 2020 Sep 22; 8(457): 1-10.
Doi:\emph{10.3389/fpubh.2020.00457}

{[}14{]} Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham
J, Marteau T. Consensus development methods, and their use in clinical
guideline development. Health Technology Assessment (Winchester,
England). 1998 Mar 1; 2(3):i-88.

{[}15{]} Batchelor JM, Ridd MJ, Clarke T, Ahmed A, Cox M, Crowe S,
Howard M, Lawton S, McPhee M, Rani A, Ravenscroft JC. The Eczema
Priority Setting Partnership: a collaboration between patients, carers,
clinicians and researchers to identify and prioritize important research
questions for the treatment of eczema. British Journal of Dermatology.
2013 Mar 1; 168(3):577-82. Doi:\emph{10.1111/bjd.12040}

{[}16{]} Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN,
Kroeker KI. An overview of clinical decision support systems: benefits,
risks, and strategies for success. NPJ digital medicine. 2020 Feb 6;
3(1):17. Doi:\emph{10.1038/s41746-020-0221-y}

{[}17{]} Meyer R. Nutritional disorders resulting from food allergy in
children. Pediatric Allergy and Immunology. 2018 Nov; 29(7):689-704.
Doi: \emph{10.1111/pai.12960}

{[}18{]} NICE. Food allergy in under 19s: assessment and diagnosis.
Clinical guideline CG116. 2011 Feb;
18p.\emph{https://www.nice.org.uk/guidance/cg116}

{[}19{]} Mortz CG, du Toit G, Beyer K, Bindslev-Jensen C, Brockow K,
Brough HA, Comberiati P, Eiwegger T, Santos A, Worm M, Ballmer-Weber BK.
When and how to evaluate for~\emph{immediate type} ~food allergy in
children with atopic dermatitis. Allergy. 2021; 76(12):3845-3848.
Doi:\emph{https://doi.org/10.1111/all.14982}

{[}20{]} TIGER study, University of
Bristol.\emph{www.bristol.ac.uk/tiger-study}

{[}21{]} Niggemann B, Binder C, Dupont C, Hadji S, Arvola T, Isolauri E.
Prospective, controlled, multi-center study on the effect of an
amino-acid-based formula in infants with cow's milk allergy/intolerance
and atopic dermatitis. Pediatric Allergy and Immunology. 2001;
12(2):78-82. Doi:\emph{10.1034/j.1399-3038.2001.012002078.x}

{[}22{]} Lever R, MacDonald C, Waugh P, Aitchison T (1998). Randomised
controlled trial of advice on an egg exclusion diet in young children
with atopic eczema and sensitivity to eggs. Pediatric Allergy and
Immunology. 1998; 9(1):13-19.
Doi:~\emph{10.1111/j.1399-3038.1998.tb00294.x}

{[}23{]} Isolauri E, Sutas Y, Makinen-Kiljunen S, Oja SS, Isosomppi R,
Turjanmaa K. Efficacy and safety of hydrolyzed cow milk and amino
acid-derived formulas in infants with cow milk allergy. The Journal of
pediatrics. 1995; 127(4):550-557. \emph{D}
oi:\emph{10.1016/S0022-3476(95)70111-7}

{[}24{]} Ridd MJ, Webb D, Roberts K, Santer M, Chalmers JR, Gilbertson
A, Marriage D, Blair PS, Turner NL, Garfield K, Coast J, Selman LE,
Clement C, Shaw ARG, Muller I, Waddell L, Angier E, Taylor J, Kai J,
Boyle RJ. Test-guided dietary management of eczema in children: A
randomized controlled feasibility trial (TEST). Clinical \& Experimental
Allergy 2021; 51(3): 452-462. Doi:~\emph{10.1111/cea.13816}

{[}25{]} Scarpone R, Kimkool P, Ierodiakonou D, Leonardi-Bee J,
Garcia-Larsen V, Prekin MR, Boyle RJ. Timing of Allergenic Food
Introduction and Risk of Immunoglobulin E-Mediated Food Allergy: A
Systematic Review and Meta-analysis. JAMA Pediatrics.~2023; 177(5):
489-497. Doi:\emph{10.1001/jamapediatrics.2023.0142}

{[}26{]} Powell~K,~Le Roux~E,~Banks~J\emph{,} Ridd MJ. GP and parent
dissonance about the assessment and treatment of childhood eczema in
primary care: a qualitative study. BMJ Open.\emph{~} 2018; 8: e019633.
Doi:~\emph{10.1136/bmjopen-2017-019633}

\section*{Tables}

{\label{tables}}

Table . Panel characteristics\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
& Number (\%)\tabularnewline
\midrule
\endhead
\textbf{Expertise} &\tabularnewline
General Practitioner with an interest in alllergy & 4
(28.6)\tabularnewline
Paediatric allergist & 3 (21.4)\tabularnewline
Paediatric dietitian & 3 (21.4)\tabularnewline
Paediatric dermatologist & 2 (14.3)\tabularnewline
Paediatrician with an interest in alllergy & 2 (14.3)\tabularnewline
\textbf{Region where exercise profession} &\tabularnewline
England -- London & 4 (28.6)\tabularnewline
Outside of England (Jersey, Scotland, Rep Ireland) & 3
(21.4)\tabularnewline
England -- South West \& South East & 3 (21.4)\tabularnewline
England -- East of England & 2 (14.3)\tabularnewline
England -- Midlands & 2 (14.3)\tabularnewline
\bottomrule
\end{longtable}

Table : Symptoms and timescales associated with an immediate
(IgE)/delayed (non-IgE) type allergic reaction to food\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllll@{}}
\toprule
\begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 1\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 1\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 1\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 1\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 1\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 2\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 2\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 2\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Round 2\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Final\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Final\strut
\end{minipage} & \begin{minipage}[b]{0.05\columnwidth}\raggedright\strut
Final\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
IgE\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Non-IgE\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
n\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
(4)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
(3)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
(3)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
(3)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Skin symptoms\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Rash, redness of skin\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Rash, redness of skin\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Rash, redness of skin\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Rash, redness of skin\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Rash, redness of skin\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Worsening of eczema (new flare) \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Worsening of eczema (new flare) \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Rough or bumpy, itchy skin\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Rough or bumpy, itchy skin\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Rough or bumpy, itchy skin\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
New eczema flare\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
New eczema flare\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
New eczema flare\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Worsening of eczema (new flare) 2-24 hours\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash)\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash) \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hives (nettle rash) \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Itching 2 hours to 2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling around the lips, face or eyes \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Gut symptoms\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea \textless{}24 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea \textless{}24 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Diarrhoea 2 hours to 2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Constipation 1-2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain/ bloating (incl. `colic')\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain/ bloating (incl. `colic')\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain/ bloating (incl. `colic')\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain/ bloating (incl. `colic')\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain/ bloating (incl. `colic')\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain \textless{} 2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Abdominal pain 1-2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Blood and/or mucus in poo 1-2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Vomiting 2 hours to 2 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Airways symptoms\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Coughing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Wheezing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Noisy or difficulty breathing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Noisy or difficulty breathing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Noisy or difficulty breathing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Noisy or difficulty breathing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Noisy or difficulty breathing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hoarse voice or cry\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hoarse voice or cry \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Hoarse voice or cry \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling of tongue or airway/ stridor\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling of tongue or airway/stridor \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Swelling of tongue or airway/stridor \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Sneezing \textless{}2 hours\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Nasal congestion or runny nose\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Key:\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Key:\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Consensus -- include\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Consensus -- include\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Not consensus\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Not consensus\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Consensus -- exclude\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
Consensus -- exclude\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.05\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table . Interpretation of SPT thresholds as negative or positive over
rounds one, two and three\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllll@{}}
\toprule
& Round & & \% panellists in agreement & \% panellists in agreement & \%
panellists in agreement & \% panellists in agreement & \% panellists in
agreement & \% panellists in agreement & \% panellists in agreement & \%
panellists in agreement & \% panellists in agreement & \% panellists in
agreement\tabularnewline
\midrule
\endhead
& & SPT wheal sizes (mm) & 0 & 1 & 2 & 3 & 4 & 5 & 6 & 7 & 8 &
9\tabularnewline
\textbf{Cow's milk} & 1 & & 92 & & & & 85 & 85 & 92 & 92 & 100 &
100\tabularnewline
& 2 & & & 92 & & & & & & & &\tabularnewline
& 3 & & & & 71 & 71 & & & & & &\tabularnewline
\textbf{Hen's egg} & 1 & & 92 & & & & 85 & 92 & 92 & 92 & 92 &
92\tabularnewline
& 2 & & & 92 & & & & & & & &\tabularnewline
& 3 & & & & 64 & 71 & & & & & &\tabularnewline
\textbf{Wheat} & 1 & & 92 & & & & & & 85 & 85 & 92 & 92\tabularnewline
& 2 & & & 100 & 92 & & & 83 & & & &\tabularnewline
& 3 & & & & & 57 & 64 & & & & &\tabularnewline
\textbf{Soya} & 1 & & 92 & & & & & 85 & 85 & 92 & 92 & 92\tabularnewline
& 2 & & & 100 & & & & & & & &\tabularnewline
& 3 & & & & 85 & 50 & 85 & & & & &\tabularnewline
\bottomrule
\end{longtable}

\textbf{Key}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
[?]80\% agreement: SPT negative interpretation\tabularnewline
\midrule
\endhead
\textless{}80\% agreement: SPT negative or equivocal
interpretation\tabularnewline
[?]80\% agreement: SPT positive interpretation\tabularnewline
\textless{}80\% agreement: SPT positive interpretation\tabularnewline
\bottomrule
\end{longtable}

\section*{Figure legends}

{\label{figure-legends}}

Figure . Dietary advice flowchart

Note: Not allergic, include = continue to include in diet or
reintroduce/introduce as normal if not currently/ever eaten; Allergic,
exclude = exclude from diet until review in allergy clinic and/or Oral
Food Challenge; Home dietary trial of exclusion = exclude food for four
weeks and reintroduce, to identify if any improvement/worsening in AD
symptoms\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

