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Rapid Responses: Rapid Responses published:
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A hysterical piece of writing
- wendy McLean (11 December 2008)
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Allergy hysteria
- O Ada Bennett (11 December 2008)
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A voice of common sense
- peter j mahaffey (11 December 2008)
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Allergies Hysteria constrains sound nutritional practice for schools, unnecessarily
- Jennette D Higgs, Joe Harvey and Kathryn Styles (12 December 2008)
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Nut-free schools are far too rare in Norway
- Inger J Bakken (12 December 2008)
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Try olives instead of peanuts
- Daniela Zauli (12 December 2008)
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Re: A voice of common sense
- Rita Hoffman (12 December 2008)
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Food allergy is only a joke if you dont have it
- Jonathan Hourihane (12 December 2008)
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The unpredictability of allergy
- Vicky Field, David Reading (15 December 2008)
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Help for nut allergy sufferers
- Grant Mooney (16 December 2008)
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Balanced and respectful dialogue needed to manage food allergies
- Laurie Harada, Susan Waserman MD (22 December 2008)
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Who's afraid of Peanuts?
- Giuseppe Paolo Mazzarello (20 January 2009)
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Counter-intuitive function of adrenaline auto-injection pens
- Per Lav Madsen, Nick Mattsson (19 March 2009)
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Re: Counter-intuitive function of adrenaline auto-injection pens
- Irene Wilson (27 March 2009)
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wendy McLean, retired home
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Professor Christakis writes in the hysterical fashion he is criticising. This is good for newspaper publicity but well below the normal BMJ standard - what was the editor thinking of? The medical advice given to parents to avoid nuts was given on the basis of previous research studies (see reference below). That advice is being increasingly questioned and may change but is not connected to the issue of how one deals with nut allergy once it is present. The issue of risk in nut allergy is a difficult one and deaths are a very poor indicator or risk. There should be few deaths since adrenaline given promptly and correctly is often - sadly not always - an extremely effective treatment. The deaths that do occur are often due to a failure to provide or use that treatment promptly. When they occur they may, if asthma is present, be recorded as caused by asthma not the allergy that precipitated the attack. Deaths are only part of the story. Even information on attendance at hospital is incomplete since those with adrenaline can and do treat an anaphylactic attack without attendance at hospital. There has been very little attempt to establish the true risks of allergy - and certainly Professor Christakis makes no attempt to do so. So - we have an unquanitified risk. What to do about that risk? If you have watched someone experiencing an anphylactic reaction and wondered if they will live or die you will know that it is distressing not only for those who experience the reaction but also for those who watch it. You will want to protect young children from that experience. Young children do not want to put their friends at risk - it is selfish parents who put their convenience before protecting a child. Naturally there has to be a balance between protecting those with allergy and the rights of other people. Evacuating a bus goes too far, cleaning it perhaps not. It is only the over-reacting Professor who talks of "decontamination". But that should be a rational debate based on a true assessment of risk - not a knee jerk reaction from a headline seeking professor. Such hysterical over-reaction leads to a climate where allergy is not seen as a risk and those who need adrenaline are not prescribed it. Shame on you BMJ for publishing this. 1. Ann Allergy Asthma Immunology 2006 Jul;97(1):10-20; quiz 21, 77 Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Fiocchi A for Adverse reactions to Foods committee, American College of Allergy, Asthma and Immunology Competing interests: child with anaphylactic reaction to nuts |
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O Ada Bennett, SpR Public Health Medicine Stonehouse, GL10 3RF
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I agree with Nicholas Christakis. Sometimes advice given about allergies can be a bit overenthusiatic (to say the least). I remember attending a talk (for new parents) given by my health visitor when I had my first child that turned out to be a nightmare. I sat there and listened to her talk about parents who feed their children any type of wheat or fish products in such terms that suggested that she thought they are poisoning their children (and would probably go to hell for it). When I asked her the rationale for this she told me that it was to prevent them developing an allergy to the products. I got so fed up of listening to this rubbish that in the end I had to remind her of two things: 1.Whole parts of Europe such as Russia where wheat is a staple food, people wean their children unto wheat-based products. In Russia the wheat product fed to children is pronounced 'manaya kasha'. I am not aware of any real increases in the rates of wheat allergies in these countries. 2. Some people (including me) originate from coastal areas or islands. Fish is the staple food there. The chances of people from such areas not feeding their children fish is probably zero. Has allergy to fish products increased in such areas? I am not aware of that. Whilst aknowledging that allergies can be life-threatening for some, I think health professionals (and other people in authority) really ought to consider the whole thing about risk perception and management and not make us all afraid of our own shadows. Competing interests: None declared |
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peter j mahaffey, consultant surgeon bedford hospital mk42 9dj
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Last week I asked an airline stewardess if I could have a bag of peanuts to accompany my pre-meal drink. "No" she replied, " there's someone on the plane with a nut allergy so we're not serving them to anyone". Our thanks are due to Prof Christakis for his blast of common sense on this issue. For some years I have struggled, as a simple surgeon, to understand the scientific background behind the multiplication in incidence of an allergy which has spread through the Western world with the ease of a contagious disease. Immunologists, too, have been remarkably reticent in providing us explanations. But everything Prof Christakis says makes sense although his rationale will be difficult, like the nuts they shelter us from, for politically correct folk to swallow. Competing interests: Nut lover |
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Jennette D Higgs, Independent Registered Dietitian/Public Health Nutritionist, Project Director Health Education Trust Health Education Trust, POBox 6057, Greens Norton, Northamptonshire, NN12 8GG, Joe Harvey and Kathryn Styles
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At long last, some common sense. As advocates for practical nutrition and health promoting advice to schools, the Health Education Trust (HET) fully supports the observations of Professor Christakis. We are a charity organisation, run by education & nutrition professionals that for the past 15 years has initiated and supported work with young people, to encourage the growth of healthy lifestyles. Although the Government’s long awaited school food standards(1) were designed to improve school food provision, the reality is that the anxieties surrounding nut allergies have all but killed off any realistic, commercially viable snacking services in our secondary schools. Unfortunately, with ‘food- on- the- go’ today’s norm, especially in schools where timetabling and long queues means a traditional main course meal is proving no solution, there is a real nutritional and social need for schools to be able to provide convenient, nutrient dense snacks for adolescents to graze on during the school day. The Government has banned the provision of all confectionary and savoury snacks in schools, allowing only dried fruit, nuts and seeds, with no added fat, sugar or salt. Research supports the positive nutritional health benefits of including nuts & seed snacks into our diets on a regular basis (2,3). It would seem therefore that the only concern with swapping the contents of the school vending machines from crisps and chocolates to dried fruit, nuts and seeds would be the need to then market these less familiar snacks to stimulate their uptake. But no, our feedback from many schools over the past year indicates that students are not being given the chance to try nut & seed snacks as the overriding anxieties and misinformation surrounding nut allergies are influencing schools decision making. And with no choice, students will continue to favour the more familiar, well marketed, high fat/sugar/salt fast foods and snacks still widely accessible just outside the school gates! Lloyd-Williams et al (4) calculated that some 6000 deaths/yr could be prevented if we substituted just one unhealthy snack (eg crisps or confectionary) with one healthy alternative (eg dried fruit & nuts), by measuring the potential reductions in death rates from CHD & stroke that could be achieved through the consequent saturated fat and salt savings. So, denying access to nut & seed snacks in schools is denying the majority of teenagers a health- promoting option. Christakis points out that there is no scientific evidence that the particular restrictions surrounding food allergies being imposed in schools are effective. Whilst we acknowledge that any serious allergic reaction is to be avoided, it does appear misguided to just dismiss the opportunity for schools to contribute to preventing some 6000 deaths in Britain. There is an alternative: schools are best placed to deliver appropriate awareness education for all on the risks, myths, realities and inclusive day to day management of food allergies. A robust risk management & educational approach in schools, that isn’t reliant on a ban, will offer the allergic child an opportunity to learn self management of their condition within the semi-protected environment of the school, so preparing them for life outside school. The UK Anaphylaxis Campaign point out that the ban approach offers only a false sense of security for the allergic child and there is of course no absolute guarantee that a school can be totally ‘nut-free’ (5). HET have developed a downloadable best practice guidance toolkit(6) designed to help schools create and manage an environment that carefully controls potential food allergens and where they are consumed, alongside raising awareness through education of appropriate handling. Specifically we focus on the potential for the much maligned vending machine to play a key role, providing a secure unit that can be clearly labelled with allergy- aware information about its contents. Interestingly, the Food Standards Agency have now recommended that Government advice on avoiding peanuts during pregnancy, breastfeeding and early life, where there is a family history of allergy, is revised in light of new evidence on exposure to peanuts in early life and the development of peanut allergy (7). However, this u-turn will no doubt create further confusion and anxiety unless sensible allergy- aware risk management advice is provided to (and by) all health professionals, aswell as schools, for the benefit of the whole community. 1. http://www.opsi.gov.uk/si/si2007/uksi_20072359_en_1 2. 2008 King, J & Allen, LH. Nuts and Health Symposium. J.Nutr. 138: 9-S1, 1734S-1765S www.nuthealth.org/press2.php3 3. 2005 Mukuddem-Petersen J, Oosthuizen W & Jerling JC. A Systematic Review of the Effects of Nuts on Blood Lipid Profiles in Humans. J. Nutr. 135: 2082–2089 4. 2008 Lloyd-Williams F, Mwatsama M, Ireland R & Capewell S. Small changes in snacking behaviour: the potential impact on CVD mortality. Public Health Nutrition. Published online by Cambridge University Press 01 Aug 2008 doi:10.1017/S1368980008003054 5. http://www.anaphylaxis.org.uk/information/schools/managing-the- condition.aspx 6. http://www.healthedtrust.com/pages/vending_in_schools-2.html 7. http://www.food.gov.uk/news/newsarchive/2008/dec/peanut08 Competing interests: HET received a grant from the American Peanut Council towards the research and development of HET's guidance toolkit for schools to manage risk of allergy from snack food provision. Jennette Higgs provides nutrition consultancy for the American Peanut Council and Californian Prune Board |
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Inger J Bakken, Senior research scientist in epidemiology SINTEF Health Research, 7465 Trondheim, Norway
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As a researcher in a contract research institute I’m used to project- based work. This semester I’ve been involved in my most important project ever with one goal: a nut-free and allergy-aware environment at the local school. The project has finally succeeded. All teachers have been informed about how seriously ill someone can become from ingestion of just traces of nuts and have also been taught first aid. All teachers now know how to use an adrenaline pen. All parents have received a letter with the information that peanut butter and other nut products no longer can be brought to school. This is by no means hysterical. Seeing a severe anaphylactic reaction and not being able to act is devastating. Probably only the accidental ingestion of nuts represents a real life threat in people with nut allergy. However, being in a room with people who devour nuts may cause a number of severe physical reactions. In theatres or cinemas, people with nut allergies can just leave the room, but in aircrafts, this becomes more problematic. Banishing nuts from schools or aircrafts is not hysterical but common sense. Competing interests: Parent of child with anaphylactic reaction to nuts |
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Daniela Zauli, Associate Professor of Allergy and Clinical Immunology Dept of Clinical Medicine,, University of Bologna-Via Massarenti 9-40138 Bologna, Italy
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What Professor Christakis writes about the fortunately low rate of death from food anaphylaxis is correct and in line with what has been published last May in an editorial of the Medical Journal of Australia (1), which I invite the discussants to have a look at. It reads that the numerical risk that a teenager allergic to peanut or tree-nut will die from anaphylaxis in the next year lies, indeed, between 1 in 10,000 and 1 in 100,000-in the same order as the chance of an Australian resident being murdered in the next year and for a child aged under 5 in the same order as the risk of being struck by lightening (1 in 1-10 million). This editorial, however, is much more concerned about the difficulties of living with the risk of food induced anaphylaxis than the article by Christakis. Although, differently from Wendy McLean and Inger Bakken, I’m not the parent of a child allergic to nuts, I ask: is it right to let these few people risk to die only to have a right to eat peanuts on board an airplane with a pre-meal drink or to have to pick up sealed tins of festive nuts not from the classrooms, but, if I understand correctly, from a different spot? Personally, I think that places like airplanes, schools, school buses, playgrounds etcetera should be highly allergenic food (nuts, crustaceans) if not free at least safe at all times. If Christakis’ children and Peter Mahaffey are not allergic to nuts, they can enjoy their peanut-based foods when they leave the school or the aircraft, cannot they? I don’t think this should be frustrating for them, it is much more so for the food allergic people and their carers. How would you like, Mr Mahaffey, to watch a child gasping for air at an altitude of more than 20,000 feet when you’re gnawing peanuts while sipping a glass of sparkling white wine? I do not at all want to offend you, but I’d suggest to try olives (green or black) instead of peanuts: they go well with aperitifs and are much safer for your air travel companions! As to the possibility of inducing peanut oral tolerance mentioned by Christakis by feeding children in their first year of life with large quantities of peanuts like in Israeli, the data reported were obtained by the use of a questionnaire and not by a randomized controlled trial. 1.Kemp AS, Hu W. Food allergy and anaphylaxis-dealing with uncertainty. MJA 2008,188.503-504. Competing interests: olive lover |
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Rita Hoffman, researcher Canada
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Dr. Mahaffey states, "For some years I have struggled, as a simple surgeon, to understand the scientific background behind the multiplication in incidence of an allergy which has spread through the Western world with the ease of a contagious disease. Immunologists, too, have been remarkably reticent in providing us explanations." It shouldn't be much of a surprise given the increased numbers of vaccinations given in all age groups. Charles Richet won the 1913 Nobel Prize for his anaphylaxis research..... http://www.medicinenet.com/anaphylaxis/article.htm "Charles Richet and Paul Portier were able to isolate the toxin and tried to vaccinate dogs in the hope of obtaining protection, or "prophylaxis," against the toxin. They were horrified to find that subsequent very small doses of the toxin unexpectedly resulted in a new dramatic illness that involved the rapid onset of breathing difficulty and resulted in death within 30 minutes. Richet and Portier termed this "anaphylaxis" or "against protection." They rightly concluded that the immune system first becomes sensitized to the allergen over several weeks and upon re-exposure to the same allergen may result in a severe reaction." The researched continued with Betty J. Hargis, Saul Malkiel and Leon S. Kind in the 50's-60's. http://www.jimmunol.org/cgi/content/abstract/104/4/942 The Journal of Immunology, 1970, 104: 942-949. Production of Hypersensitivity in the Neonatal Mouse Researchers today create animal models of anaphylaxis using vaccines and their ingredients. Nonmurine Animal Models of Food Allergy http://www.ehponline.org/members/2003/5705/5705.html "In the atopic dog model for food allergy (Ermel et al. 1997), newborn pups (day 1) were subcutaneously injected in the axillas with 1 µg of cow's milk, beef, ragweed, and wheat extracts in alum. Food antigen was again administered on days 22, 29, 50, 78, and 85. At ages 3, 7, and 11 weeks, all pups were vaccinated with attenuated distemper-hepatitis vaccine. Immunized pups responded with allergen-specific IgE by week 3 and peaked at week 26 of age." Is it a stretch to think that the vaccines are causing anaphylaxis in the general population? Competing interests: Parent of a child with anaphylaxis to numerous foods and latex. |
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Jonathan Hourihane, Professor of Paediatrics and Child Health University College Cork, ireland
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Christakis’s commentary smacks of nimbyisim (Not In My Back Yard- ism) because he has been inconvenienced by his school’s response to the issue of sealed tins of festive nuts. If his own child were nut allergic I imagine his response would have been different. I agree that the institutions’ actions, as reported by Christakis appear to be rather over-elaborate. However, the use of emotive language like “evacuation” and “decontamination” is not helpful. Cutaneous contact with peanut allergens can cause allergic reactions. 10 year old children are much more likely than 2 year olds to fool around on a bus or to intimidate a peanut allergic child with a discovered peanut. Such bullying is a fact of life for peanut allergic children (DunnGalvin et al, Clin Exp Allergy 2008;38(6):977-86. doi 10.1111/j.1365-2222.2008.02978.x ). There is elision of a couple of issues in Christakis’s essay:
It is “hysterical” (to use Christakis’s or BMJ’s own word) to speak emotively of a “hidden, deadly danger in so innocent a thing as a snack in kindergarten”. Snack sharing is a risk to people with peanut allergy and although the behaviour may be innocent, the risk is considerable and real for children affected by food allergies; even considering just first reactions to peanut, 3% occur in school and 22% in day care facilities (Greene et al Pediatrics 2007;120;1304-1310, doi: 10.1542/peds.2007-0350). More than half of fatalities due to food allergy occur outside the home (Pumphrey and Gowland J Allergy Clin Immunol 2007 Apr;119(4):1018-9, doi:10.1016/j.jaci.2007.01.021). There is no such thing as “meaningless” allergies to nuts, or else we have to accept the terms “meaningless” asthma and " meaningless" cancer. I think Christakis means false positive tests that are not associated with clinical reactivity. Show me a medical test that has no false positives. What we need is better access to expert care. Comparing nut allergic reactions with lightening strikes, gunshot wounds and traumatic brain injuries due to road traffic accidents is fatuous in the extreme. Simple avoidance of nuts is the most effective (in fact the only) strategy we have for controlling food-related anaphylaxis at present. The removal of guns from American streets would practically eliminate childhood deaths from gunshot accidents. The number of deaths from motor vehicle collisions would be even higher without seatbelts, which have been compulsory in the United Kingdom and most of Europe for nearly 30 years. Laws are enacted to address known hazards to public health whether they are common (seatbelts but no gun control in the US) or unusual (current dioxin “scare” in Ireland). The societal cost of any intervention must be weighed but Americans with Disabilities and other groups have laws enacted to protect them from discrimination and disadvantage. Limiting the type of snack that children eat near food allergic children is a reasonable response, when reasonably applied. Competing interests: I believe food allergy is a serious condition. I have received speakers fees from companies that distribute adrenaline autoinjectors |
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Vicky Field, Communications manager The Anaphylaxis Campaign, Farnborough, GU14 6SX, David Reading
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Peanut and nut allergies are notoriously unpredictable. Many people who have experienced mild or moderate symptoms are at risk of more severe reactions during a later exposure. People who live with nut allergy every day of their lives are dealing with a very real problem that may be life-threatening and is likely to be life-long. Yes, of course there are extreme feelings among the parents of allergic children but in many cases this is because they have witnessed a real medical emergency. There is no evidence that nut bans in UK schools are on the increase. But we do know that most schools are implementing effective management plans and protocols which work well and keep the allergic child safe. The bus incident described in the article is just one incident that happened in the US. We know that there are hundreds of families coping sensibly and working with school staff to sound yet sensible safety protocols. The Campaign believes that educating parents and children is of utmost importance. Knowing about your allergy, triggers, emergency protocols and carrying your medication at all times works well to reduce anxiety and risk and incidents such as that described in the article. For information and advice call our dedicated helpline on 01252 542029 or visit www.anaphylaxis.org.uk Competing interests: The Anaphylaxis Campaign is a UK registered charity which provides information and support to people affected by severe allergy and has received educational grants from food companies and pharmaceutical companies. |
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Grant Mooney, Retired G.P. Retired from Kelso TD5 7LF
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I greatly appreciated Prof. Christakis article highlighting the over- reaction to nut allergy.However I can recollect the stress endured by parents in trying to find nut free products for their offspring suffering from nut allergy. This is not helped by powerful food producers, such as Cadburys, labelling their products "May contain nuts". Surely these large companies should be obliged to have two production lines , one which is totally nut free and the other used for nut containing products. This would ensure that these companies need not fear being sued as their product would clearly state "Nut free" or "Contains nuts". Competing interests: None declared |
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Laurie Harada, Executive Director Anaphylaxis Canada, Toronto, Ontario, Canada M2J 5B4, Susan Waserman MD
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In public discussions about anaphylaxis, allergists and allergy associations urge empathy, perspective and reason. Unfortunately, these elements are lacking in the article by Dr. Nicholas Christakis (British Medical Journal, December, 2008). To support his thesis that there exists a public hysteria over management of food allergies, the author relies on disingenuous comparisons, hyperbolic examples and early research. An avoidable death is tragic regardless of how it happens. Dr. Christakis wonders if “restrictions being imposed are effective or … warrant the costs incurred”, as he compares the number of individuals dying from food allergies versus those from automobile accidents or sports injuries. What Dr. Christakis fails to recognize is there are preventative tools already at the disposal of car drivers (seat belts, speed limits) and athletes (equipment, referees). For those individuals with severe food allergies, preventative tools include avoidance, education and community cooperation. These latter strategies take time and patience to develop but are sound, long-term investments for people at risk of anaphylaxis as well as the broader community. For parents who have watched their children struggle for life’s breath after eating something to which they were allergic, such as a peanut, the incentive to avoid re-living that experience can be overwhelming. It can also create heightened concern for those who are tasked with their care. In the absence of a cure, this rational desire can sometimes lead to irrational responses. It is likely from these types of circumstances that Dr. Christakis has chosen a couple of colourful examples to underscore his argument of widespread hysteria over food allergies. This is terribly unhelpful to the millions of families around the world with children at risk of anaphylaxis who are diligently trying to calmly educate their children while living with a fear that is genuine. His arguments also ignore the credible evidence that is contrary to his views. Consider that in the province of Ontario (Canada), the government passed in 2006 Sabrina’s Law – a policy requiring all publicly funded schools to have reasonable measures in place to protect children at risk of anaphylaxis. The concept of Sabrina’s Law has since spread to other parts of Canada and other countries. Real and reasonable solutions, not radical reactions, are being created in a spirit of co-operation and are having a positive impact on the lives of allergic students. One of the great challenges surrounding food allergies is that so little is still known. How much of a certain food is needed to cause a reaction in a particular person? How do we even know for certain who is at risk of a fatal reaction? It is therefore misleading for Dr. Christakis to rely on a research study focused on allergy prevention to support a separate point about management strategies for the known food allergic. In fact, Dr. Christakis cites the results of one UK study on early exposure to peanut, offering that current recommendations for the “wholesale avoidance of nuts” contributes to the problem of more children being sensitized. While it is an interesting theory that early exposure to peanut may build tolerance it is important to note that the study's investigators state that their findings “raise the question of whether early and frequent ingestion of high-dose peanut protein during infancy might prevent the development of peanut allergy through tolerance induction” (Journal of Allergy and Clinical Immunology 2008;122:984.doi:10.1016/j.jaci.2008.08.039). It is a precarious platform from which to suggest that avoidance of common allergens is counterproductive. We believe that everyone’s interests are well served when measures that lessen the risk of an allergic reaction are adopted in a climate of compassion and cooperation, not fear or confrontation. Laurie Harada, Executive Director, Anaphylaxis Canada Susan Waserman MD, FRCPC, McMaster University, Hamilton, Canada Competing interests: Susan Waserman and Laurie Harada have received honoraria for education initiatives from companies which distribute epinephrine auto-injectors. Anaphylaxis Canada (www.anaphylaxis.ca) is a national non-profit group which supports and advocates for people at risk of anaphylaxis. The organization has received educational grants from the food and financial sectors and pharmaceutical companies and worked on contract for the Ontario Ministry of Education to develop educational resources which support the implementation of Sabrina’s Law. Harada is the parent of a child with multiple food allergies (peanut – and other legumes - tree nuts, and shrimp). |
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Giuseppe Paolo Mazzarello, Family Doctor Genoa 16127
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I agree with Dr. Christakis on his serious and deep considerations about this issue. However I would talk of "phobia" from somebody more than "epidemic hysteria". The mass shows more compliance than sharing with those who are phobic. Today the concept of public well-being is unluckily more sensitive to phobia than common sense. I have realized that Dr. Mahaffey and Dr. Hoffman share this last word in their responses. Drawing his "Peanuts" today Mr. Schulz would be less lucky. Competing interests: None declared |
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Per Lav Madsen, MD DMSc Dept. of Cardiology, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen Ø, Denmark, Nick Mattsson
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Illogical over-treatment (1) as well as plain wrong self-treatment of type I allergy are problems to be considered. In patients with type I allergy and established systemic reactions, treatment includes self-injection of adrenaline with prefilled devices, in the case of the EpiPen® constructed to look somewhat like a ballpoint pen. Unfortunately the EpiPen® is constructed as an upside-down sort of pen, in the sense that the needle emerges from what at first glance seems to be the button end of the pen, not the end where one would expect the ink-covered ball-point tip to emerge. Consequently, during the 2008 wasp season, we experienced two cases of adverse self- injection in the thumb. Sixty-seven patients with wasp stings were seen, sixteen of whom presented with systemic allergic reactions: six of the sixteen were already known with such reactions and had attempted auto-injection of adrenaline. In two of the six patients the procedure was wrongly performed: one auto-injected into the thumb, and another never received adrenaline because his daughter, a consultant in anaesthesia, auto-injected into her thumb trying to help him. Most adrenaline self-treatments are correctly performed, but our unfortunate patients are not alone (2-5), and in a study using EpiPen® dummies, sixteen of one hundred doctors injected into their thumb when trying to demonstrate a correct auto-injection (6). Incorrect self-injection is life threatening and not easily avoidable through education if doctors, even including a consultant in anesthesia, cannot perform the procedure correctly. Adrenaline auto-injection treatment must be based on a 100% self-evident injection procedure. Nick Mattsson* MD and Per Lav Madsen*# MD DMSc
References 1. Christakis NA. This allergies hysteria is just nuts. BMJ 2008 De 10; 337: a2880. 2. Mol CJ, Gaver J. A 39-year-old nurse with accidental discharge of an epinephrine autoinjector into the left index finger. J Emerg Nurs 1992; 18: 306–9. 3. McGovern SJ. Treatment of accidental digital injection of adrenaline from an autoinjector device. J Accid Emerg Med 1997; 14: 379–80. 4. Turner MJA, Purushotham AD. Accidental Epipen® injection into a digit – the value of a Google search. Ann R Coll Surg Engl 2004; 86: 218–9. 5. Skorpinski EW, McGeady SJ, Yousef E. Two cases of accidental epinephrine injection into a finger. J Allergy Clin Immunol 2006 Feb; 117(2): 463-4. 6. Mehr S, Robinson M, Tang M. Doctor - how do I use my EpiPen? Pediatr Allergy Immunol 2007 Aug; 18(5): 448-52. Competing interests: None declared Editorial note
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Irene Wilson, UK Mastocytosis Support Group Leader 8 Selm Park, Livingston, EH54 5NU
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I am the UK Mastocytosis Support Group Leader. Many in our group have serious anaphylactic reactions and have to use an Epipen. Sometimes two Epipens are required during a serious reaction. Three people have injected into their thumb by mistake. It is very easy to do. I constantly send out instructions to my group and explain the correct way to use the pen and the importance of medical treatment if injected wrongly.
Irene Wilson
UK Mastocytosis Support Group Leader
www.ukmasto.co.uk
e-mail: winegums@blueyonder.co.uk
Competing interests: None declared |
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