Among a group of children treated for food-related anaphylactic reactions over 6 years, 12 percent needed a second epinephrine dose, according to a report out today in the journal Pediatrics. Anaphylaxis is a severe allergic reaction that develops quickly, within seconds or minutes of exposure, causing potentially life-threatening symptoms like difficulty breathing.

Prior studies found similar results. One found that nearly one in five severe food-induced allergic reactions will require more than one epinephrine shots.

Taken together, these studies add weight to the recommendation that children at risk for severe food-related allergic reactions carry two doses of epinephrine, note Dr. Susan A. Rudders of Children's Hospital Boston and colleagues.

Food allergy affects up to 6 percent of children and, by most estimates, seems to be rising. Appropriate treatment involves an immediate self-administered shot, or two, of epinephrine, available in convenient pre-loaded devices, such as EpiPen.

In the new study, Rudders and colleagues report on some 1200 children, about 6 years old on average, who were treated at two Boston hospitals for food-related allergic reactions between 2001 and 2006.

When they narrowed the group to those with a severe food-induced anaphylactic reaction (52 percent), they found 44 percent of children received epinephrine and among this subset, 12 percent received more than one dose.

Before arriving at the hospital, 31 percent of children with a severe reaction received one dose of epinephrine and 3 percent received two doses. Once at the hospital, 20 percent received one dose of epinephrine and 1 percent received more than one dose.

SEVERE REACTIONS STILL MISSED, UNDER-TREATED

What's troubling, the researchers say, is that half of the children with food-induced anaphylactic reactions did not get epinephrine either before getting to the hospital or while at the hospital. At the hospital, the children received antihistamines, steroids, intravenous fluids and inhaled medicines more often than epinephrine, despite the lack of evidence for their usefulness as a first-line treatment, the authors note.

Additionally, fewer than half of the children with food-related allergic reactions left the hospital with a prescription for self-injectable epinephrine and only 22 percent were advised to see an allergist.

Clearly, food-related anaphylaxis continues to be under-recognized and inadequately treated, Rudders and colleagues warn. Estimates suggest that approximately 150 to 200 people die each year from food-related anaphylactic reactions, and delayed or lack of administration of epinephrine is often to blame.

Confirming prior reports, common offending foods in the children studied included peanuts, tree nuts, milk, shellfish, fish, and eggs. Surprisingly, however, say the researchers, fruits and vegetables -- foods typically thought to have a low propensity to cause allergic reactions -- were also triggers. Most of the children with severe reactions to food had the typical signs and symptoms -- skin rash, itching, swelling, trouble swallowing and breathing, nausea and vomiting.

People with a history of severe food-related allergic reactions should be prescribed and taught how to use self-injectable epinephrine, Rudders and colleagues note in their report, and they should carry two doses with them at all times.

Medicine