Food allergy: gambling your life on a take-away meal

Assessing of patients’ knowledge of anaphylactic shock and allergies

Background: The World Health Organization (WHO) identified allergy as one of the major problems of the 21st century. It was also stated to be a key issue for health protection and public health care activity in the White Book on Allergy published in 2011. An allergy or atopy is called type I hypersensitivity. It may take the form of immediate (anaphylaxis) or late symptoms including allergic rhinitis and eye diseases, atopic dermatitis, food allergies, anaphylactic shock, allergic asthma and hives. Anaphylaxis and anaphylactic shock can occur at any age. Aim of the study: The goal of the study was to assess patient knowledge about allergies and appropriate actions to take in situations of severe allergic symptoms including anaphylactic shock. Material and methods: The study was conducted in 2018 among 150 adult patients in a clinic of Allergy at Optima Medycyna SA in Opole. The author’s survey questionnaire contained 27 closed single or multiple-choice questions. Results: A satisfactory level of knowledge of the most life-threatening allergy exacerbations was found in 79.3% (119) of the examinees. 53.3% (80) had correct knowledge of how to act in the case of a severe allergic shortness of breath and symptoms that do not subside despite administering medications. In such instances, 46.7% did not know what to do. Only 84.7% (127) of respondents knew the definition of anaphylactic shock while 10% (15) did not know the concept at all. Conclusions: Patients showed a significantly higher level of knowledge about allergy complications than about their causes and prevention. Knowledge about the diagnosis of allergy exacerbations, as well as steps to take in life-threatening situations associated with acute allergic disease and anaphylactic shock in home situations was insufficient. In addition, it was found that nursing staff insufficiently educate patients on allergies and associated complications.

Parent perceptions in managing children with food allergy: An Australian perspective

INTRODUCTION

Food allergy affects up to 10% of Australian children, and living with food allergic children can be challenging for parents. This study explored parental perceptions and knowledge as they navigate a new reality of keeping their child safe.

METHODS

Parents of children with food allergies completed an online food allergy survey in 2015. Questions explored health knowledge, skills, and attitudes (KSAs) as well as quality of life (QoL) through the inclusion of the Food Allergy Quality of Life - Parental Burden instrument (FAQL-PB). Notification of the survey included advertisements to more than 700 randomly selected Australia-wide preschools, 44 allergy specialists, and Allergy & Anaphylaxis Australia. Responses were tabulated and analysed.

RESULTS

Of the 400 participants who logged on, 357 commenced the survey and 318 finished. Questionnaire analysis showed that 44.1% of parents (n = 135) hesitated to use an adrenaline auto-injector and may be influenced by a classification system where symptom severity is not universally understood. While 79% would sign up to a national Anaphylaxis Registry, intention to participate in clinical trials using vaccines was disclosed by only 56%. Allergen labelling and community acceptance continue to be the most challenging aspects of managing a food allergy, and 50% of parents reported that food allergy played a role in choosing a preschool or primary school. Overall, quality of life for participants was influenced more by gender (male) and age of the child than where they lived - capital city or regional location; however, regional participants were more frustrated over lack of appreciation relating to the seriousness of food allergy (p = 0.010).

CONCLUSION

Results highlight the need for educational strategies for both the food allergy community and public, particularly in regional areas, since there is a perceived lack of appreciation as to the seriousness of food allergy. Educational resources and relevant networks are required to support parents and caregivers in the management of children with food allergy.

“Know before You Serve”

Given the potential severity of allergic reactions to certain foods, restaurant operators and staff need to know how to prevent guests from eating what could be fatal food. When the state of New Jersey enacted a law to create a fact sheet to explain safe handling of food allergens, a research team examined the information and communication challenges regarding food allergens— including knowing what foods cause the most trouble and how to avoid cross-contamination. The team then created a fact sheet that depicts the suspect foods and explains specifically how to avoid triggering food allergies in guests. This fact sheet will be displayed in all restaurants in the state.

Dietary management of peanut and tree nut allergy: what exactly should patients avoid?

Peanut and tree nut allergies are the commonest cause of life-threatening food-allergic reactions and significantly affect quality of life in children and their families. Dietary nut avoidance and provision of emergency medication is currently the mainstay of treatment. Nut avoidance has consequences on both quality of life and nutrition. We review the terminology that may cause confusion and lead to unnecessary dietary restrictions. In peanut or tree nut-allergic children, introduction of specific nuts to which the child is not allergic may improve quality of life and should be considered in patients with multiple foods allergies, vegan or ethnic-specific diets, in whom nuts are an important source of protein. Nut-allergic consumers do not just need to avoid foods containing nuts as an ingredient, but also contend with pre-packed foods which frequently have precautionary allergen labelling (PAL) referring to possible nut contamination. Although the published rate of peanut contamination in 'snack' foods with PAL (see Box ) ranges from 0.9-32.4%, peanut contamination in non-snack items with PAL is far less common. We propose that in some peanut-allergic patients (depending on history of reactivity to trace levels of peanut, reaction severity, other medical conditions, willingness to always carry adrenaline, etc.), consideration may be given to allow the consumption of non-snack foods containing PAL following discussion with the patient's (and their family's) specialist. More work is needed to provide consumers with clearer information on the risk of potential nut contamination in pre-packed food. We also draw attention to the change in legislation in December 2014 that require mandatory disclosure of allergens in non-pre-packed foods.

Is food allergen analysis flawed? Health and supply chain risks and a proposed framework to address urgent analytical needs

Food allergy is an increasing problem. If we fail to realise the promise of current risk assessment and risk management of food allergens through lack of ability to measure them reproducibly and with traceability to an international unit of measurement, the analytical community will have failed a significant societal challenge.

Food allergy, a summary of eight cases in the UK criminal and civil courts: effective last resort for vulnerable consumers?

Food allergy has a forensic context. The authors describe eight cases in the UK courts involving fatalities, personal injury or criminal non-compliance with food law from mainly 'grey' literature sources. The potentially severe consequences for people with food allergy of contraventions of labelling law have led to enforcement action up to criminal prosecution for what might otherwise be regarded as 'trivial' non-compliance. The authors suggest there should be central collation of such cases. Non-compliances should be followed up in a more rapid and robust manner. Evidence of fraud in the catering supply chain supports recent calls for zero tolerance of food fraud. Businesses must guard against gaps in allergen management, for which there are readily available sources of training and guidance, but also against fraudulent substitution in the supply chain, about which training and guidance should be developed. New allergen labelling legislation and case law appear to place responsibility on food businesses even for the forensically problematic area of allergen cross-contamination. The courts can be an effective last resort for vulnerable consumers; however, there is evidence of knowledge and skill gaps in both the investigation and prosecution of potentially serious incidents of food allergen mismanagement and mislabelling. Thorough investigation of food allergy deaths is required with a tenacious and skilled approach, including early realisation that samples of the food and/or stomach contents from a post mortem examination should be retained and analysed. The supply chain must be rigorously examined to find out where adulteration or contamination with the fatal allergen occurred.

Detection of relevant amounts of cow's milk protein in non-pre-packed bakery products sold as cow's milk-free

BACKGROUND

Currently, there is no mandatory labelling of allergens for non-pre-packed foods in the EU. Therefore, consumers with food allergy rely on voluntary information provided by the staff. The aim of this study was to characterize allergic reactions to non-pre-packed foods and to investigate whether staff in bakery shops were able to give advice regarding a safe product choice.

METHODS

Questionnaires were sent to 200 parents of children with a food allergy. Staff of 50 bakery shops were interviewed regarding selling non-pre-packed foods to food-allergic customers. Bakery products being recommended as 'cow's milk-free' were bought, and cow's milk protein levels were measured using ELISA.

RESULTS

A total of 104 of 200 questionnaires were returned. 25% of the children experienced an allergic reaction due to a non-pre-packed food from bakery shops and 20% from ice cream parlours. Sixty percent of the bakery staff reported serving food-allergic customers at least once a month, 24% once a week. Eighty four percent of the staff felt able to advise food-allergic consumers regarding a safe product choice. Seventy three 'cow's milk-free' products were sold in 44 bakery shops. Cow's milk could be detected in 43% of the bakery products, 21% contained >3 mg cow's milk protein per serving.

CONCLUSION

Staff in bakery shops felt confident about advising customers with food allergy. However, cow's milk was detectable in almost half of bakery products being sold as 'cow's milk-free'. Every fifth product contained quantities of cow's milk exceeding an amount where approximately 10% of cow's milk-allergic children will show clinical relevant symptoms.

EAACI food allergy and anaphylaxis guidelines: managing patients with food allergy in the community

The European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines, managing patients with food allergy (FA) in the community, intend to provide guidance to reduce the risk of accidental allergic reactions to foods in the community. This document is intended to meet the needs of early-childhood and school settings as well as providers of non-prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast-food outlets) and targets the audience of individuals with FA, their families, patient organizations, the general public, policymakers, and allergists. Food allergy is the most common trigger of anaphylaxis in the community. Providing children and caregivers with comprehensive information on food allergen avoidance and prompt recognition and management of allergic reactions are of the utmost importance. Provision of adrenaline auto-injector devices and education on how and when to use these are essential components of a comprehensive management plan. Managing patients at risk of anaphylaxis raises many challenges, which are specific to the community. This includes the need to interact with third parties providing food (e.g., school teachers and restaurant staff) to avoid accidental exposure and to help individuals with FA to make safe and appropriate food choices. Education of individuals at risk and their families, their peers, school nurses and teachers as well as restaurant and other food retail staff can reduce the risk of severe/fatal reactions. Increased awareness among policymakers may improve decision-making on legislation at local and national level.

Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children (STOP II): a phase 2 randomised controlled trial

BACKGROUND

Small studies suggest peanut oral immunotherapy (OIT) might be effective in the treatment of peanut allergy. We aimed to establish the efficacy of OIT for the desensitisation of children with allergy to peanuts.

METHODS

We did a randomised controlled crossover trial to compare the efficacy of active OIT (using characterised peanut flour; protein doses of 2-800 mg/day) with control (peanut avoidance, the present standard of care) at the NIHR/Wellcome Trust Cambridge Clinical Research Facility (Cambridge, UK). Randomisation (1:1) was by use of an audited online system; group allocation was not masked. Eligible participants were aged 7-16 years with an immediate hypersensitivity reaction after peanut ingestion, positive skin prick test to peanuts, and positive by double-blind placebo-controlled food challenge (DBPCFC). We excluded participants if they had a major chronic illness, if the care provider or a present household member had suspected or diagnosed allergy to peanuts, or if there was an unwillingness or inability to comply with study procedures. Our primary outcome was desensitisation, defined as negative peanut challenge (1400 mg protein in DBPCFC) at 6 months (first phase). Control participants underwent OIT during the second phase, with subsequent DBPCFC. Immunological parameters and disease-specific quality-of-life scores were measured. Analysis was by intention to treat. Fisher's exact test was used to compare the proportion of those with desensitisation to peanut after 6 months between the active and control group at the end of the first phase. This trial is registered with Current Controlled Trials, number ISRCTN62416244.

FINDINGS

The primary outcome, desensitisation, was recorded for 62% (24 of 39 participants; 95% CI 45-78) in the active group and none of the control group after the first phase (0 of 46; 95% CI 0-9; p<0·001). 84% (95% CI 70-93) of the active group tolerated daily ingestion of 800 mg protein (equivalent to roughly five peanuts). Median increase in peanut threshold after OIT was 1345 mg (range 45-1400; p<0·001) or 25·5 times (range 1·82-280; p<0·001). After the second phase, 54% (95% CI 35-72) tolerated 1400 mg challenge (equivalent to roughly ten peanuts) and 91% (79-98) tolerated daily ingestion of 800 mg protein. Quality-of-life scores improved (decreased) after OIT (median change -1·61; p<0·001). Side-effects were mild in most participants. Gastrointestinal symptoms were, collectively, most common (31 participants with nausea, 31 with vomiting, and one with diarrhoea), then oral pruritus after 6·3% of doses (76 participants) and wheeze after 0·41% of doses (21 participants). Intramuscular adrenaline was used after 0·01% of doses (one participant).

INTERPRETATION

OIT successfully induced desensitisation in most children within the study population with peanut allergy of any severity, with a clinically meaningful increase in peanut threshold. Quality of life improved after intervention and there was a good safety profile. Immunological changes corresponded with clinical desensitisation. Further studies in wider populations are recommended; peanut OIT should not be done in non-specialist settings, but it is effective and well tolerated in the studied age group.

FUNDING

MRC-NIHR partnership.

Strategies for living with the risk of anaphylaxis in adolescence: qualitative study of young people and their parents

BACKGROUND

Adolescents with anaphylaxis are at increased risk of fatal outcomes. Gaps in their knowledge of day-to-day and emergency management have been identified. There are also gaps in services available to support adolescents at risk of anaphylaxis.

AIMS

To explore the experiences and healthcare needs of adolescents living with the risk of anaphylaxis; to understand the perspectives of their parents; and to look at how care might be improved.

METHODS

A qualitative study was undertaken using in-depth interviews with adolescents with a recent history of severe allergic reactions and with their parents.

RESULTS

Twenty-six adolescents at risk of anaphylaxis living in Scotland and their parents (n=28) were recruited. Most anaphylactic reactions reported by participants appeared to result from accidents, misinformation, or inexperience. For many, management involved finding a balance between taking their allergies seriously whilst not allowing these concerns to dominate their lives. Risks were often difficult to judge, with reactions sometimes taking place even after careful checking of meal ingredients. Most admitted taking some risks with trace-labelled foods. Appropriate healthcare support for adolescents in learning to manage the risk of anaphylaxis independently and advice and support for their parents was inconsistently provided.

CONCLUSIONS

Adolescents tend to see their risk management strategies as 'good enough', but these strategies were often inconsistent with clinical best practice and, in some cases, had not prevented reactions. Building on adolescents' existing skills and knowledge and the use of Internet and associated social media resources may help to support more effective self-management among adolescents.

A qualitative study of families of a child with a nut allergy

OBJECTIVES

The aim of this study was to explore, using qualitative methods, the experiences of children and their parents living with nut allergy.

METHODS

Children with a confirmed diagnosis of peanut allergy were identified from a database of patients maintained at an allergy clinic at a large teaching hospital. Interviews with 26 families were conducted involving 11 children, 25 mothers and 12 fathers.

RESULTS

The diagnosis of nut allergy signalled a critical transition-or biographical disruption-in the life of the family. Parents took on the role of 'alert assistant' and sought to create 'safe places' where nuts were not permitted, but often struggled when outside the home environment. The option of 'passing as normal', often used by people with a chronic illness to avoid stigma, was not available to them. Consequently, parents often reported being treated as faddy, demanding, and neurotic, and children suffered from teasing and exclusion. The social consequences of nut allergy were worsened by poor labelling and control of foods and products containing nuts.

DISCUSSION

In many ways, nut allergy may be considered a form of disability, because it imposes social barriers on participating fully in society.