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  Allan F Colver
  Published on: 22 March 2016
• Incidence of Severe and Fatal Reactions to Foods
  S Allan Bock, MD
  Published on: 22 March 2016
• The importance of managing food allergy among children
  David M Reading
  Published on: 22 March 2016
• How dangerous is food allergy?
  Jane Salter
  Published on: 22 March 2016

• Published on: 22 March 2016

  Authors reply

  • Allan F Colver, Paediatrician

  Dear Editor

  We thank Bock et al. for their interest in our article. We respect their views on the interpretation of the data but it is of course for each reader to come to their own opinion on these. We would like to respond to their comments on the accuracy and valididity of our data.

  Did our paper under-ascertain deaths? Bock et al. base their concerns on our methods of case ascertainment...

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  Dear Editor

  We thank Bock et al. for their interest in our article. We respect their views on the interpretation of the data but it is of course for each reader to come to their own opinion on these. We would like to respond to their comments on the accuracy and valididity of our data.

  Did our paper under-ascertain deaths? Bock et al. base their concerns on our methods of case ascertainment and on comparison with another study. We cannot be certain about this but as the text indicated we used many sources and spoke to many experts in the field. We agree we did not search local newspapers but this would have been almost impossible as few were on CD-ROM in the 1990s. As mentioned, we did search national newspapers and all cases we came across were already known through one of our other sources. Finally, since publication, no-one has told us of a case we appear to have missed.

  We specifically studied children up to 15 years because this is the group we were interested in. Many recommendations on risks to children are based on inferences from data covering all ages and we wanted to bring a proper paediatric perspective. Indeed the interpretation Bock et al give to the paper they cite [1] is grossly misleading. They suggest extrapolation to a US population would lead to 200 deaths from food each year; yet the paper , in which there is only one death (occurring during exercise), covers all ages and reactions to all allergens, not just food

  The issue of whether asthma deaths may have been precipitated by food allergy is an important question which we addressed “If a child’s symptoms are only asthmatic and no allergen is suspected, then there is no means for attributing such reactions to food or for knowing if a causal link exists”. Further, such deaths will never have been reported in surveys of food allergy in other countries or in other age groups. No group has been able to address this question satisfactorily and it is a key area for further research.

  We are not sure we agree that children, who have self-administered epinephrine, often do not go to hospital. However we do not know the proportion and said as much, excluding this group from our definition of severity.

  Finally we agree that education of professionals and the public should continue based on the best data available. This must include those parents whose children are truly at high risk as well as those many parents that think any immediate hypersensitivity reaction to food means their child is at high risk of an allergic death; when in reality the risk, in the absence of asthma, seems very small. Different parents will come to different views about how to proceed faced by a severe but very small risk, just as we all do in many aspects of our lives.

  Allan Colver
  Colin Macdougall
  Andrew Cant
  

  Reference

  (1) Yocum M W, Butterfield J H, Klein J S et al. Epidemiology of anaphylaxis in Olmsted County: a population based study. J Allergy Clin Immunol 1999:104:452-6

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Incidence of Severe and Fatal Reactions to Foods

  • S Allan Bock, MD, Allergist
  • Other Contributors:
    • Jonathan Hourihane, David Reading, Pete Smith, David Hill, Gideon Lack, Anne Munoz-Furlong

  Dear Editor

  Although the article by Macdougall et al. [1] regarding the incidence of severe and fatal reactions to food would be seem to be reassuring, we would like to express some concerns and raise some questions about the data presented. The first question is whether the ascertainment of cases is really as complete as the authors suggest. We acknowledge that the UK medical system may allow better r...

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  Dear Editor

  Although the article by Macdougall et al. [1] regarding the incidence of severe and fatal reactions to food would be seem to be reassuring, we would like to express some concerns and raise some questions about the data presented. The first question is whether the ascertainment of cases is really as complete as the authors suggest. We acknowledge that the UK medical system may allow better reporting and access to mortality data than that of the US. However, the records acquired as described seem to represent the same underreporting issues as those in the US. Is it really unlikely that the BPSU misses a significant number of cases? Based upon a well characterized population in Olmstead county Minnesota and extrapolating the data to a US population of 280 million, it may be estimated that there are 200 deaths from anaphylaxis reactions to food each year. [2]

  A paper published in 2001, described methodology in which a National Registry had been established and was well publicized to US allergists. [3] Very few reports were made by allergists and none by other physicians. No cases were initially reported by physicians who conduct research in food allergy. Nearly all the cases were ascertained from the press. These news articles appeared in local newspapers and were not reported in media with a large regional or national circulation. In an earlier effort to account for all cases of food anaphylaxis, only in Colorado, a significantly higher number of cases were reported from rural regions as compared to metropolitan areas strongly suggesting either misdiagnosis or inaccurate recording of cases in the emergency department log of busy hospitals. [4]

  A second concern is the reporting of cases only up to age 15. In the paper mentioned above, of 32 fatalities 10 occurred in youngsters up to age 15.[3] An additional 10 occurred in adolescents aged 16 to 19. Why did MacDougall et al. not include all adolescents?

  A third question must always be raised when fatal food anaphylaxis is studied. Is it not possible that cases of fatal asthma were actually initiated by unidentified allergic reactions to food? All authors in this field are likely to agree that the ultimate cause of death may be irreversible airway obstruction, and all would agree that poorly controlled asthma increases the risk of fatal anaphylactic reactions to food, but we would suggest that the trigger responsible for individual asthma fatalities is not always determined. What about fatalities that never reach the emergency department and are misclassified on death certificates as asthma fatalities? Individuals that die at home and are classified as asthma deaths are unlikely to be further investigated in either the US or the UK.

  Fourth the authors’ definition of severity seems incomplete. Individuals with severe food reactions who self-administer epinephrine often do not go to hospital, are less likely to have reactions that require hospitalization or cause death, and often they do not report these reactions to their physicians unless specifically queried. Some survive the reaction without treatment, become convinced that they know to avoid a specific food, and never tell their physician. We could argue about the possible progression of these episodes to near-fatal or fatal reactions, but the point to be made is that they are frequently under- reported. Fifth would be the issue of the safe administration of epinephrine. We disagree about the risk to children of the administration of a single dose of epinephrine as opposed to withholding that dose. We have no disagreement about aggressive treatment of asthma concurrently, and in fact we think that point should be emphasized. However families reading this commentary may become more fearful, than they currently are, about administering epinephrine. We know that epinephrine is not always life saving even when administered in a timely fashion, [5] however withholding it surely must increase the risk of calamity. Over dosage certainly may occur, but it seems more likely that an overdose would be administered by medically trained personnel than by parents. The over prescription of epinephrine is a debatable issue, however it seems a small price to pay, with a low risk, in order to save even one young life.

  Finally, we are very concerned that families will interpret this paper to mean that death from food allergy is very unlikely, and therefore they may relax their vigilance. If families of younger children become less concerned when their children become adolescents it may to difficult to institute a good prevention education program. This is exactly the opposite of the goal of education programs in the US (The Food Allergy and Anaphylaxis Network, www.foodallergy.org) and UK (The Anaphylaxis Campaign) aimed at making individuals with food allergy and the general population more aware of the problem and the potential for mortality. It is truly unfortunate that we cannot accurately identify all of the individuals who die during allergic reactions to food and use this information to do a better job of preventing these tragedies. We must continue our campaigns of education of medical professionals and the public, and we must be certain that emergency treatment is available when and where it is needed.

  S Allan Bock, MD
  Anne Muñoz-Furlong
  USA
  

  Jonathan Hourihane, MD
  Gideon Lack, MD
  David Reading
  United Kingdom
  

  David Hill, MD
  Pete Smith, MD
  Australia
  

  References

  (1) Macdougall CF, Cant AJ, Colver AF. How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland. Arch Dis Child 2002;86:2236-9.

  (2) Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD. Epidemiology of anaphylaxis in Olmstead County: A population-based study. J Allergy Clin Immunol 1999; 104:452-6.

  (3) Bock SA, Munoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001;107:101-3.

  (4) Bock SA. The incidence of severe adverse reactions to food in Colorado. J Allergy Clin Immunol1992;90:683-5 1992.

  (5) Sampson HA. Peanut allergy. N Engl J Med 2002;346:1294-8.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  The importance of managing food allergy among children

  • David M Reading, Director of patient support group

  Dear Editor

  As a patient organisation supporting people with severe allergies, the Anaphylaxis Campaign views with some concern your report entitled “How dangerous is food allergy in childhood?” [1]

  The authors conclude that the risk of a fatal allergic reaction among children under 13 is small, and the inference seems to be that the problem has been vastly exaggerated.

  No one would argue that parent...

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  Dear Editor

  As a patient organisation supporting people with severe allergies, the Anaphylaxis Campaign views with some concern your report entitled “How dangerous is food allergy in childhood?” [1]

  The authors conclude that the risk of a fatal allergic reaction among children under 13 is small, and the inference seems to be that the problem has been vastly exaggerated.

  No one would argue that parents of food-allergic children should be helped to lower the anxiety levels in their lives. But the danger with this report is that it goes too far the other way and may lead to a dangerous over-confidence among the families affected by severe allergy and also among doctors, schools, child carers, and the food industry.

  Medical experts would be better qualified to discuss the flaws in the study’s methodology – and as a layman I would conclude there appear to be many – but let us accept that the level of risk among allergic children is indeed low. Why should this be so? We believe one answer must be that allergic children are usually closely supervised by adult carers, who scrutinise food labels, question restaurant staff, and ensure that medical treatment is obtained quickly when a reaction occurs. It would be a mistake to reduce this high level of care for food-allergic children, and for health professionals, school staff and the food industry to conclude: “So it’s not a serious problem then?”

  The authors acknowledge that the risks increase for teenagers and young adults. Perhaps this is yet another reason for remaining well-prepared while children are younger. For if they learn the lessons of managing their allergy before they reach their teens, they will be well equipped to cope once they “fly the nest”. Conversely, if they are taught it is “no problem” it will be difficult to persuade them otherwise during the more risky years.

  Equally worrying, GPs may become reluctant to prescribe epinephrine injection pens to children when they genuinely need them. The report’s abstract makes the definitive observation that a child with a mild food allergy died from epinephrine overdose, but fails to state that this was intravenous epinephrine, not delivered by auto-injector. In the text such a statement is made, but many readers and literature searches will only see the abstract and get a very misleading message.

  Having an epinephrine kit appears to provide an assurance to patients, parents and child carers alike that they are not powerless; they have a means to protect themselves. You could use the car seatbelt analogy: “you’ll probably never need it, but it’s there in case you do.” [2]

  It would be disastrous if this report actually increased the risks for allergic children by persuading their families – and those who care for them – that the sensible protective measures they take are unnecessary.

  References

  (1) Macdougall CF, Cant AJ, Colver AF. How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland. Arch Dis Child 2002;86(6): 236-9.

  (2) Hourihane J O’B. Controversies in paediatrics. Arch Dis Child 2001;85(6):512-3.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  How dangerous is food allergy?

  • Jane Salter, MD
  • Other Contributors:
    • Peter Vadas MD, Saral Mehra, James Cairns MD, Gordon Sussman MD

  Dear Editor

  Re: Macdougall C. How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland.[1] I would like to share a Canadian perspective on anaphylaxis deaths, as our findings and conclusions differ from those of Drs CF Macdougall et al. Their British study found that 8 children died from food-related anaphylaxis over a 10-year period in the UK...

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  Dear Editor

  Re: Macdougall C. How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland.[1] I would like to share a Canadian perspective on anaphylaxis deaths, as our findings and conclusions differ from those of Drs CF Macdougall et al. Their British study found that 8 children died from food-related anaphylaxis over a 10-year period in the UK and Ireland. The pediatric population base was 13 million. Four deaths were caused by milk. Peanuts/nuts did not seem to play a significant role even in non-fatal reactions.

  In Ontario, Canada we found that 11 of 32 food allergy deaths between 1986 and 2000 occurred in children (coroner's office). Unlike the British study, peanuts/nuts caused 10 of the 11 deaths. There were no documented pediatric deaths from milk. The population of Ontario age 0-15 years is below 2.5 million; less than 20% of the population size sampled in the British study.

  Further, the peak age for food-related anaphylaxis deaths in Ontario was between 15 and 25 years of age. This age group was excluded from the British survey.

  Given population differences, the lower British/Irish death rate, particularly for peanut/nut, is surprising. This could be an artifact of differences in study design and data capture. It could also reflect true differences between Canada and the UK. Peanut butter, for example, is much less popular in Britain.

  Also, in Dr Macdougall's study, patients who responded to one dose of epinephrine were excluded from the severe reaction category ... this is misleading as it allows treatment success to interfere with measurement of incidence.

  Further to this point, one death was caused by an intravenous epinephrine overdose. This was an iatrogenic death and the study does not underscore the potential life-saving benefits of early i.m. administration of epinephrine.

  It is also important to note that for someone living with a potentially life-threatening food allergy, the risk of death may be relatively low. Death from anaphylaxis, however, can be prevented, making even one death unacceptable.

  In our study, 30/32 victims had had previous reactions. For five, their symptoms had been so mild that they had never reported them to a physician. As it is not currently possible to predict who might have a fatal reaction, we recommend that all people with allergies to peanuts, tree nuts and shellfish, regardless of degree of previous reactivity, be prepared to deal with an anaphylactic emergency. Others need to be assessed on an individual basis.

  Parents should be reassured that, provided they obtain an accurate diagnosis and follow current, recommended guidelines, their children will be well-protected. As teens and young adults appear to be at greatest risk, early childhood is the key time to prepare children for the more challenging years ahead.

  Reference

  (1) Macdougall CF, Cant AJ, Colver AF. How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland. Arch Dis Child 2002;86:236-239.

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  Conflict of Interest:
  None declared.

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