Lifetime management: increasing rates of food anaphylaxis

ANAPHYLAXIS is a serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. Prompt identification and treatment with intramuscular adrenaline is paramount, as delayed administration is associated with fatal anaphylaxis. In Australia, the recent introduction of a new adrenaline autoinjector (AAI) means that clinicians now have the choice of prescribing either an EpiPen (available in 150 mcg or 300 mcg) or an Anapen (available in 150 mcg, 300 mcg or 500 mcg). Given the administration methods are different, patients and carers must receive device-specific anaphylaxis action plans and training.

As children grow, the burden of anaphylaxis management shifts from the parent to self-management. This requires clinicians to evolve their approach towards food anaphylaxis management at each stage of the patient’s life, taking account of age-specific management barriers and opportunities to deliver optimal care for our patients.

Infants and young children

Australia has the highest rate of food allergy in children globally, with one in 10 infants having challenge-proven food allergy, and anaphylaxis presentations to a tertiary paediatric emergency department in children under 2 years increased 3.6 times over a 10-year period.  In early childhood, the burden of food anaphylaxis management falls solely on parents and caregivers.   Toddlers require constant vigilance to prevent them grabbing allergenic foods or placing contaminated toys or hands in their mouths.  Anaphylaxis in young children is frequently under-recognised and can lead to delayed treatment.  This can be due to the limitations in verbal communication skills, and the symptoms of an allergic reaction (e.g. vomiting, irritability) are also frequently observed in other common paediatric presentations (here, and here). Parents who previously experienced only milder allergic reactions or who are facing their first allergic reaction, may not have had formal specialist assessment, and hence may be ill-equipped in recognising anaphylaxis. Unexpected allergic reactions can occur when children are given new foods in day care.  Hence, anaphylaxis training programs for parents and carers in this vulnerable non-verbal age group must focus on increased awareness and the early recognition of anaphylaxis. Children weighing 7.5 kg to 20 kg may be prescribed either an Anapen junior 150 or EpiPen junior 150.

In children attending kindergarten or pre-primary school, signs of anaphylaxis are more defined and children can start verbalising their symptoms. However, children’s food intake at school is less supervised and contamination may occur through food-sharing. Individual and any general-use AAIs should be stored in a secure yet easy-to-access location in each childcare setting.

The constant vigilance required by parents to monitor a young child with food allergies can negatively impact the child’s sense of autonomy and emotional health.  Consequently, clinicians should support parents by helping them feel confident in anaphylaxis management, thus empowering them to continue encouraging their child to safely explore the world around them.

School-aged children and adolescents

As children enter school age, they start sharing in the ever-increasing responsibility in managing their own allergies. Parents are advised to meet with the school to discuss their child’s food allergies, implement risk-minimisation strategies, discuss the appropriate storage of their child’s AAI, and to provide a copy of their child’s  anaphylaxis action planhttps://allergyfacts.org.au/resources/help-sheets/starting-school-with-food-allergies. Children are educated on not sharing foods at school, and to promptly tell a teacher if they are having an allergic reaction.

In children >20 kg, the AAI needs to be upgraded from either an EpiPen Junior 150 to the EpiPen 300, or from the recently released Anapen Junior 150 to the Anapen 300. Physicians and carers have a wide range of perception regarding when a child should be expected to self-recognise symptoms of anaphylaxis (age 9-11 yo) or to start carrying and using their own AAI (age 12-14 yo), which is ultimately dependent on the child’s developmental level and risk of severe anaphylaxis.

As children enter adolescence, they experience rapid biological, emotional and social changes.  Critically, teenagers and young adults with food allergies are at the highest risk of anaphylaxis fatalities. Barriers toward successful anaphylaxis self-management unique to adolescents include insufficient disease knowledge, suboptimal cognitive and coping skills, higher emotional intensity and a lack of surrounding social support.  This leads to increased risk-taking behaviour, lack of adherence towards health care advice, and poor decision-making during allergic reactions.

The cornerstone of management therefore involves the repeated education and training of the young adult in how to manage their allergic reactions. Points for emphasis include:

• discussing the reasons for carrying their AAI at all times, as majority do not and the majority of reactions occur outside of home;
• helping the teenager recognise which specific symptoms (e.g. difficulty breathing, wheezing) should trigger the use of their AAI;
• emphasising the importance of maintaining a supine posture during an allergic reaction to prevent sudden cardiovascular collapse; and,
• having the adolescent demonstrate how they would administer their own AAI.

Adolescents should be offered practical advice to avoid food allergy reactions in high-risk social situations, such as attending parties, eating at restaurants, ice cream parlours, kissing, and alcohol consumption. The importance of checking food labels cannot be overemphasised. A high proportion of food anaphylaxis fatality cases have asthm and the clinician plays a vital role in ensuring that this, along with other co-morbidities, are optimally controlled. Management should be scaffolded with a respectful and supportive approach by the clinician and parents, and the young adult encouraged to seek peer-support by reaching out to friends and patient support organisations.

Adults

For many people, food allergy will be a lifelong condition requiring tailored management throughout adulthood. Similar to children, food anaphylaxis admission rates in Australian adults are also increasing, and the median age of food anaphylaxis fatalities in Australia is 28 years.

Although many food allergies start in early childhood, up to half of adults may have their first allergic reaction during adulthood. Adults with a suspicious history of possible food allergy should be promptly referred to an allergy specialist.

Adults’ complacency in anaphylaxis self-management is common. The proportion of people at risk of anaphylaxis who have a current AAI prescription declines with age, with only around one-third of university students reporting they always carry their AAI, while less than 10% of adults with anaphylaxis receive pre-hospital treatment with adrenaline. Although the absolute risk of fatal food anaphylaxis is low (estimated annual risk between 1 in 100 000 to 1 in one million), deaths do occur in adults, including in those who previously had only mild to moderate reactions. Additionally, co-factors, such as sleep-deprivation or exercise, can lower reaction thresholds.  New challenges are presented for young adults with food allergy when moving into a share house or residential college with communal dining room, and travelling; useful resources are available at www.250k.org.au. In some cases, adults are prevented from pursuing a chosen career, as people with food allergy are unlikely to be accepted to the Australian Defence Force.

Therefore, clinicians managing adults should consistently reinforce measures to prevent (e.g. always reading food labels, declaring one’s allergy whenever ordering from a food service provider), recognise and manage anaphylaxis promptly.

Pregnant people can be reassured that they can safely receive intramuscular adrenaline, while recovery should be in the left lateral position or by performing manual left uterine displacement to improve venous return. While the association of food allergy with increased anxiety and poor mental health seen in children and adolescents may wane by adulthood due to better coping strategies, clinicians should remain alert to the significant impact that food allergies may have on the quality of life and mental health of an individual.

Timely recognition and prompt treatment with adrenaline is central in reducing the risk of fatal anaphylaxis. The barriers to effective management change as the child grows, and, hence, clinicians play a vital role in the successful delivery of anaphylaxis training to parents and patients, tailoring health-care advice in accordance to the patient’s changing needs at every developmental stage of life – from infancy through to adulthood.

Associate Professor Kristina Rueter is a consultant paediatric immunologist, general paediatrician and emergency physician at Perth Children’s Hospital. Her academic appointment is with the Division of Paediatrics at the Medical School of The University of Western Australia. She is the deputy chair of the ASCIA anaphylaxis committee. She is a member of the Centre for Food and Allergy Research at the Murdoch Children’s Research Institute and of the Child Allergy and Immunology Research Group at the University of Western Australia. 

Dr Michael O’Sullivan is a consultant clinical immunologist at Perth Children’s Hospital and Fiona Stanley Hospital, and immunopathologist at PathWest. He is an Honorary Research Associate at Telethon Kids Institute, Clinical Senior Lecturer at UWA, and a Director of ASCIA and member of the anaphylaxis, education and paediatric committees.

Dr Dean Tey is a paediatric allergist and immunologist from the Department of Allergy and Immunology, Royal Children’s Hospital, Melbourne and Honorary Fellow at the Murdoch Children’s Research Institute. He is the Chair of the ASCIA Annual Scientific Conference in Melbourne, 2022.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.