Food allergies may be common enough to affect one in every 16 children, but a parent of a 3-year-old with allergies finds little comfort in statistics. Especially when they are aware that food allergies can be serious and that deaths do happen, although very rarely. As Professor Jonathan Hourihane, a specialist on children’s allergies, points out: ‘much (parental) anxiety relates to the lack of confidence that families have in their family doctors, who may not be very knowledgeable about allergies.’ (1)
The situation in the UK
Unlike many other developed countries, we have very few medical allergy specialists in the UK. As a result we lack an infrastructure for proper advice and treatment both in primary care and hospital services.
It is therefore extremely important that both the parents and children themselves have sufficient knowledge to deal with an allergic event if the occasion arises.
Incidence of food allergy
Let us look at a few statistics. The Food Standards Agency estimates that there are between five and 15 fatalities every year in the UK associated with food allergies. However, between 1992 and 2002, only 10 children under 15 died as a result of a severe food allergy, so the actual risk of a child with food allergy dying from an allergic reaction is about one in 800,000 per year, although higher in those with asthma. Four of those deaths were from milk, but no child below 13 died from peanut allergy. However near-deaths and severe reactions are commoner.
While some might find it reassuring that food allergy deaths are extremely rare, it is nevertheless very frightening for a child suffering an allergic reaction to know that other children have died! What helps most in these situations is a well thought out plan of action rather than simple reassurances that ‘it is unlikely to happen’. In dealing with food allergies in children it is important to be prepared for the worst, while hoping for the best. Despite being easy to administer, allergy treatment is not always successful, so diagnosis and prevention are crucial.
Allergens and allergy tests
Fortunately, more than 90% of food allergies can be put down to eight foods: milk, peanuts, eggs, fish, shellfish, soya, wheat, tree nuts and seeds.
In many cases, tests are scarcely needed, as it is fairly obvious what is causing the reaction. Allergy tests can themselves cause severe reactions, although this is rare, but since it is impossible to predict beforehand who will and who will not react, it is best that the tests are carried out in hospitals.
If your child has had an allergic reaction and you are unsure why, it is quite reasonable to request your doctor to arrange an allergy test for the common food allergies.
Unfortunately serious allergic reactions can often be neither predicted nor prevented. This lack of predictability is one of the most important aspects of allergies that everyone should understand. In most instances it is impossible to predict which children are likely to suffer from a serious allergic reaction, either from their history or by any laboratory test. In his 2004 study (2) Richard Pumphrey showed that of those who died from a serious food allergic reaction, only 20% had had a serious allergic reaction in the past.
Of course, if there is a history of asthma or previous serious food allergy, it makes sense to be extremely cautious and try to avoid exposure at all costs. But what about those children who have had only ‘mild’ reactions?
Mild or serious?
The word ‘mild’ means little if your child has food allergy. It means he or she is at risk of getting a severe allergic reaction, however small that risk may be. Being unduly concerned about this is not helpful, as your own anxiety may distress your child. Risk is a matter of perception which needs acting upon. In this regard, severe allergic reactions should be viewed as similar to road accidents (although far less common). They are unavoidable, although safety precautions can help to reduce the risk substantially.
The first step is to get educated with accurate, reliable information.
As a practising doctor, I find the job of ‘reassuring’ parents of children with a food allergy quite difficult. How can I reassure anxious parents by saying that ‘it may affect your child anytime’, ‘and he or she might die without warning, although the odds are extremely low’?
In my opinion, continued support and education is a far more effective approach. The vast majority of ‘mild reactions’ can be treated simply with anti-histamines. But mild allergic reactions need just the same work-up as severe ones, and it is imperative to be well prepared just in case.
Because asthma is a well known factor that can predict a severe allergic reaction affecting the airways (anaphylaxis), children with asthma and their parents are often well prepared with inhalers, steroids and even adrenaline injections in many cases. A lot of them are under constant medical supervision, which helps in this regard.
But we need to deliver much more information and support for children with food allergies and their families than we are at present. For instance, parents would be far more reassured if all schools and nurseries were trained to cope with acute allergic reactions instead of relying on their local surgeries for emergency treatment if or when the need arises.
Allergy or intolerance?
It is also important to realise that many perceived ‘allergies’ are not true acute allergies so it is important to record symptoms carefully looking for a consistent pattern of swollen lips or eyes, skin rashes, hives or wheezing coming on within minutes to a maximum of two hours of intake of a specific food. Many symptoms such as diarrhoea, dizziness or sickness, which are associated with food intake, are not symptoms of acute allergy, and may be simply ‘intolerance’.
Delayed symptoms (a wide variety of gut and general health symptoms) that appear from hours to several days after the intake of certain foods do not indicate an acute food allergy but some other problem.
It is important that acute allergy be distinguished from the host of other vague and often chronic reactions which are often wrongly thought by patients to be allergies. The best way to prove an acute food allergy is a skin prick test; blood tests at hospitals (RAST tests) are not as accurate. But once the allergy is proven it has to be taken seriously until the child outgrows it – remembering however, that some allergies such as peanut allergy often last for life.
Once it is confirmed that your child is one of the 6% in their age group who has got acute food allergy, the next step is to educate everyone in the family about it.
Your child has to learn that food that other children are having at school may be dangerous, and he or she must call for help as soon there are any symptoms after eating.
Avoidance of allergens needs to be a family effort in which everyone plays a role: creating, finding and collecting recipes free of egg, soya, nuts etc; reading composition labels on products on supermarket shelves; talking to chefs before ordering when eating out; wearing medical alert emblems and tags and always knowing exactly where to find ‘rescue’ medications - bronchodilator inhalers, steroid inhalers or injections, and in some rare life-threatening instances, injectable adrenaline.
Adrenaline must be part of the family’s emergency allergy kit, and although some specialists have reservations about its safety used outside hospitals, there is little doubt that it empowers families to lead ‘normal’ lives with their allergic children.
It is important that families should get themselves trained to manage emergencies related to allergy. If the local hospital has an allergy clinic that is good news as it means that there is a source of help and guidance. For others it may need more work - books, magazines websites, seminars and discussion rooms.
Food allergy is here to stay, and it is getting commoner. But the vast majority of allergic children grow up to lead healthy lives. However, to ensure that they do, their families need to accept the allergy and deal with it head on, armed with information and an action plan. Just as they would deal with most other
difficult situations in life.
(1) Hourihane JO. Are the dangers of childhood food allergy exaggerated? BMJ. 2006 Sep 2;333(7566):496-8. Review.
(2) Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol 2004;4: 285-90
First published in 2007
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