Poor Vigilance Cited for Infant Reactions to Food Allergies

James Brice

June 25, 2012

June 25, 2012 — A preschool child with an allergy to milk, egg, or peanut has an 80% chance of having at least 1 allergic reaction each year, according to a new study, and caretaker inattention appears to play a significant role.

David M. Fleischer, MD, from National Jewish Health, Denver, Colorado, and colleagues reported their results in an article published online June 25 in Pediatrics. The 3-year observational study, performed at hospitals in Baltimore, Maryland; Denver; Durham, North Carolina; Little Rock, Arkansas; and New York City involved 512 infants with a median age of 35.5 months (range, 0 - 48.4 months). All the children had common allergies to milk, eggs, and peanuts.

The investigators provided parents with food allergen avoidance advice, in both written and oral form, for specific foods. They also gave parents written emergency plans for self-injectable epinephrine, the authors write. The advice given followed 2000 American Academy of Pediatrics guidelines.

Investigators gathered clinical data for each child during visits scheduled twice yearly for the first year, and then annually for 2 more years, and they also made telephone contact with parents between the visits.

Despite the parent training and other precautions, the researchers found that the annualized rate of reactions for all foods was 0.81 (95% confidence interval, 0.76 - 0.85). The study recorded 1171 reactions in 367 (71.7%) children over the course of 3 years of observation.

The researchers attributed nearly two thirds (64.9%) of accidental allergic reactions to milk, egg, or peanut to a lack of vigilance in checking ingredients and supervising children and to errors in reading ingredient labels and in preparing foods safely. This suggests a need for more education to avoid reactions, the authors note.

"Half (50.6%) of all allergic reactions were attributed to food not provided by parents," the authors write. Daycare personnel, babysitters, and family members often unknowingly fed children food that triggered a reaction, they note.

"[O]nly 29.9% of severe reactions were treated with epinephrine," the researchers write. Epinephrine is a therapy of choice for childhood food allergies. More specifically, the investigators found 65 severe reactions in which the parent or caretaker "failed to administer epinephrine even though they felt it was indicated," the authors point out.

The finding suggests that many parents lack either the training or the confidence to use the standard EpiPen (Dey Pharma) device for administering the injectable treatment.

The authors also found it worrisome that 11.2% of the reactions arose from purposeful ingestion of known food allergens, although some of these incidents may have been associated with parents who were testing whether their child had outgrown their allergy to specific foods.

The study offers a more thorough assessment of the frequency and circumstances that lead to reactions among infants and very young children with food allergies, according Ruchi Gupta, MD, MPH, assistant professor of pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, who was not involved in the study. The previous understanding of these trends was largely based on case reports and anecdotal information.

"It actually gives us some knowledge that reactions are occurring frequently in these infants, who are often not responsible for their own food or feeding themselves," she told Medscape Medical News in an interview.

In addition, the findings help pediatricians identify opportunities for quality improvement, especially by extending educational efforts to all caregivers involved with the affected child, Dr. Gupta said. Training should include recommended actions to assure vigilance and training in EpiPen usage to give caregivers the confidence required to administer treatment in response to allergic reactions.

"It is really important to make all caretakers at the daycare center or in other settings aware of what a food allergy is, how to read food labels to avoid incidents, and what to do in case of accidental ingestion," she said.

The study's limitations included an inability to identify all reactions. Voluntary parental reports may have included inaccuracies from faulty recollections or a reluctance to report reactions to purposeful exposures, and the study focused only on certain allergies. In addition, minority and economically disadvantaged and highly advantaged populations were all underrepresented in the patient sample.

This study was supported by the National Institutes of Health (NIH)–National Institute of Allergy and Infectious Diseases (NIAID). The project was also supported by grants to National Jewish Health, the Mount Sinai School of Medicine, the University of Arkansas for Medical Sciences, Duke University Medical Center, and Johns Hopkins University School of Medicine from the National Center for Research Resources, a component of the NIH. Authors also received research support from the NIH-National Heart, Lung, and Blood Institute, the Marion B. Lyon Award, the Food Allergy & Anaphylaxis Network and the Wallace Research Foundation, the National Peanut Board, the Food Allergy Initiative, and Dyax Corp. Dr. Fleischer and one coauthor are consultants for Sunovion. One coauthor is a consultant to the Asthma and Allergy Foundation of America and is on the Medical Advisory Board of the Food Allergy & Anaphylaxis Network. One coauthor is a consultant for ActoGeniX NV, Intelliject, McNeil Nutritionals, Novartis, and Schering-Plough; is a minority stockholder in Allertein and MastCell Inc; is on the advisory board for Dannon Co Probiotics; is on the expert panel for Nutricia; has provided legal consultation services/expert witness testimony in cases related to food allergy; is on the Medical Board of Directors for the Food Allergy & Anaphylaxis Network; is a Dermatological Allergy Committee member for American College of Allergy, Asthma, and Immunology; is a Study Section member for the National Institutes of Health; Hypersensitivity, Autoimmune, and Immunemediated Disorders; serves on the reviewer board for the Journal of Allergy and Clinical Immunology; and is a member of the Food and Drug Administration. One coauthor serves on the Medical Advisory Board for the Food Allergy & Anaphylaxis Network and is a steering committee member for sanofi-aventis. One coauthor is on the Medical Board of Directors for the Food Allergy & Anaphylaxis Network, is a consultant to the Asthma and Allergy Foundation of America, is a consultant for Allertein LLC, is a consultant/scientific advisor for the Food Allergy Initiative, and is 45% owner of Herb Springs LLC. One coauthor is a consultant for the Food Allergy Initiative and is an advisor for the Food Allergy & Anaphylaxis Network. The other authors and Dr. Gupta have disclosed no relevant financial relationships.

Pediatrics. Published online June 25, 2012.

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