Food allergy in childhood

Have the dangers been underestimated? Macdougall et al have tried to assess the risks of food allergy in childhood by identifying the incidence of fatal and severe reactions.1 They conclude that the risk of death is small and play down the importance of severe food reactions. The implication is that epinephrine (adrenaline) autoinjectors are overprescribed. This paper has serious consequences for the management of children with food allergy, so the methodological problems need to be explored to provide a balanced view. The data produced are likely to be misleading by underestimating both severe and fatal reactions. This is at a time when there is evidence in the UK of a doubling of admissions for anaphylaxis (1991–95),2 385 of whom were children (60 caused by food, but in 240 aetiology was not recorded).3 Food is the commonest cause of anaphylaxis in children,3–5 and in an American series nuts were the commonest cause of fatal food allergic reactions.6 This study will underestimate the incidence of fatal reactions, because the authors incorrectly assume that all such deaths will be correctly registered as allergy (or related terms). Anaphylactic reactions are often mislabelled as asthma deaths, because of a lack of antecedent history or information. This is clear from retrospective analysis of fatal reactions.7,8 For example, we know of a teenager who died of almond anaphylaxis, but the cause of death was given as asthma alone. The true cause of death only came to light when the Confidential Inquiry into Asthma Deaths9 lead by serendipity to case review by an allergist (PWE) who knew of the case. There are four deaths per million per annum in 5–14 year olds10 apparently caused by asthma, 60-fold more than the deaths identified in the Macdougall et al study. …