Guidelines for food-induced anaphylaxis must be updated, urge researchers

Most food-induced anaphylaxis deaths in children were attributed to airway and breathing problems and could have been prevented if adrenaline treatment was delivered in time, new studies find.

Two studies, published in Clinical & Experimental Allergy and conducted by researchers from the University of Bristol and Bristol Children’s Hospital, examined data from the National Childhood Mortality Database (NCMD) on fatal food-induced anaphylaxis in children.

The researchers identified key interventions that could help prevent future tragedies and are now calling for those at risk of food-induced anaphylaxis to have better access to adrenaline autoinjectors (AAIs) and for NHS guidelines to be updated to focus more on breathing issues than heart and circulatory failure.

Professor Karen Luyt, programme director for the NCMD and professor of neonatal medicine at the University of Bristol, said: ‘Every child’s death is a profound loss. By learning from every child death, we can identify where systems, services and support need to be improved to protect children’s lives.’

The first study examined the factors contributing to 19 food-induced anaphylaxis deaths in children between 2019 and 2023. It found that in 14 cases (74%), no AAI – such as an EpiPen – was administered before cardiac arrest, or only a single dose was given.

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In six cases (32%), the child or carers did not carry any AAIs, and in one case, only one AAI was available, preventing a second dose from being administered promptly. According to the researchers these findings highlight a major point of intervention and underscore the need for better access to AAIs for those at risk of food-induced anaphylaxis.

Dr Tom Roberts, clinical lecturer in emergency medicine at the University of Bristol and a co-author of the research, said: ‘Anaphylaxis from a food allergy is a life-threatening emergency requiring immediate adrenaline.

‘While EpiPens work quickly to reverse symptoms by reducing swelling and opening up airways, our research reveals that in many cases, children did not receive enough adrenaline before cardiac arrest, and some didn’t carry an AAI at all.

Dr Roberts added: ‘There is a very short window of time, often just minutes, in which appropriate treatment can potentially alter the clinical course of these events. Delays in delivering adrenaline treatment, which sometimes may require more than one dose, can have fatal consequences.’

In the second study, the same group of researchers analysed the timeline of events of fatal food anaphylaxis to identify lessons for improving hospital management.

Of the 17 cases included in the study, where the failed bodily system that led to death could be identified, an analysis revealed that in all but one case, lung failure was the primary cause of death.

According to the authors, this finding is significant, as current NHS guidelines focus on heart and circulatory failure, suggesting that children who reach the hospital may not get the most effective emergency treatment they need, in the time they need it.

Dr John Covney, the study’s lead author from Bristol Children’s Hospital, said: ‘NHS guidelines currently focus on heart and circulatory failure in emergency management, our findings suggest that the focus should be on breathing issues, which were by far the most frequent cause of death in the cases we analysed.

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‘Circulatory problems without breathing issues were rare, indicating that updated guidelines should prioritise airway and breathing management in these critical situations.’

Dr Ben McKenzie, an emergency medicine doctor from the University of Melbourne, and a lead author of a similar Australian analysis, said: ‘This UK research, confirms our Australian findings that fatal food anaphylaxis is driven by a closing of the airways in the lungs.

‘We need to promote the chain of survival in anaphylaxis – get help, give adrenaline and, for healthcare workers, get oxygen into the body as a priority.’

Previous research on deaths from asthma and anaphylaxis found that most fatal cases were triggered by food and occurred in the home, public spaces, or schools, highlighting the need for improved pre-hospital management to prevent child deaths.

In 2024, a Lancet study revealed that food allergy rates have doubled between 2008 and 2018, with an increase in childhood cases. Moreover, according to Anaphylaxis UK, hospital admissions for food allergies in children have increased by 600% over the past two decades.

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According to EpiPen UK, current guidance for patients at risk of anaphylaxis is that they should always have two AAIs available to them. Yet a study from last year highlighted that fewer than half of school-age children in England at risk of food allergy have been prescribed a potentially life-saving AAI.

A version of this article was first published by our sister title, The Pharmacist.