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Management of young boy with cashew nut allergy (10HDC00458)

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(10HDC00458, 17 January 2012)

Cashew nut allergy ~ Anaphylaxis ~ Asthma ~ General practitioner ~ General paediatrician ~ Adrenaline auto-injectors ~ Learning opportunities

This case study summarises the Commissioner's consideration of a case involving the care provided by a general practitioner (the GP) and a general paediatrician (the paediatrician) to a young asthmatic boy with a cashew nut allergy. Sadly, the boy died following an anaphylactic reaction to cashew nuts. This summary concludes by outlining learning opportunities associated with the case.

Background

The boy had a history of reactions to cashew nuts, which was first noted in September 2004 (at age 4) when he reacted to cereal and developed an itchy skin rash. He was treated successfully with Phenergan (an antihistamine).

In October 2004, a blood test was arranged through his GP which confirmed the presence of IgE antibodies to a group of four nuts, including cashew nuts. In December 2004, the GP referred the boy to a paediatrician who had seen him previously on other matters, including asthma which had developed in 2001. In January 2005, the boy had a further reaction - a sore stomach with no rash - to a sandwich containing a spread/dressing containing cashew nut.

The paediatrician reported back to the GP in March 2005 that he had discussed allergy types with the boy's mother and that the boy did not, on that occasion, seem to have had either an anaphylactic or anaphylactoid reaction. The option of an EpiPen® (auto-adrenaline delivery device) was discussed, but since he had responded well to Phenergan the paediatrician felt that continuing with that would be a satisfactory option.

Further reaction

In April 2005, the boy ate some dip containing traces of cashew nut and suffered a more pronounced type of reaction: an asthmatic-type cough, welts, snuffly nose and runny eyes, and he complained of difficulty breathing. He was given two doses of Phenergan and settled two hours later.

His mother arranged a further appointment with the paediatrician in August 2005. The paediatrician's report stated "I explained to [his mother] that [the boy] seems to have had an anaphylactoid type reaction and therefore I would have a low threshold to having an EpiPen which only needs to be used in cases of anaphylaxis".

The paediatrician did not arrange any further follow-up, but reviewed him again in July and August 2007 in relation to his deteriorating asthma. The GP advised that between August 2005 and June 2009 there was no consultation at which it became necessary to discuss the allergy in the context of his ongoing asthma management.

The boy's mother said that, based on the discussion with the paediatrician, she gained the impression that the reaction was anaphylactoid, and that this was not as serious as anaphylactic reaction and "was the second in a three stage continuum". She advised that she did not understand that her son's condition could be life-threatening. She acknowledged that there was a discussion about the use of an EpiPen®, and her impression was that the paediatrician did not consider an EpiPen® necessary. Consequently, it was decided to continue treating any reaction the boy suffered with Phenergan and prednisolone. The GP recorded in her notes in August 2005 under "long term classifications" that the boy had a food allergy, being an anaphylactoid type reaction to nuts. After 2005, his parents tried to avoid their son being exposed to cashews, and he had no known exposure to cashews between April 2005 and June 2009.

The boy was at a friend's home in June 2009. The parent caring for the children gave them cashew nuts. They had not been told of the boy's allergy. The boy did not recognise the nuts, and reacted to them. His parents collected him and took him to a nearby medical centre. The boy walked into the medical centre unaided. Adrenalin was administered and centre staff spoke to the Emergency Department (ED) at the local (tertiary) hospital. However, his condition then quickly worsened and an ambulance was called. Further adrenalin was given and an oral airway was inserted as the ambulance arrived. A back-up ambulance was called to assist with his airway. This ambulance transported him to hospital where, sadly, he died.

Coroner's report

In November 2009, the Coroner issued his findings that the boy died when he had an anaphylactic reaction to the ingestion of cashew nuts, causing status asthmaticus. The initial report from the pathologist stated that status asthmaticus was attributable to cashew nut sensitivity. This opinion was reviewed following submissions made by the boy's parents, and included information from another paediatrician. The submissions raised issues about the cause of death. The pathologist amended the cause of death to status asthmaticus attributable to cashew nut anaphylactic hypersensitivity.

The second paediatrician also commented on the availability of EpiPens® in New Zealand. He referred to a 2006 article in the New Zealand Medical Journal which suggested that New Zealand had fallen behind the UK, North America and Australia in the provision of adrenaline auto-injectors, such as EpiPens®.

The Coroner commented on the expense involved with the purchase of EpiPens® in New Zealand. While the Coroner was unable to say if the availability and use of an EpiPen® would have prevented the boy's death, he recommended that Pharmac review its decision not to fund the provision of adrenaline auto-injectors as a treatment for individuals at risk of anaphylaxis.

Complaint

Paediatrician

The boy's parents complained to HDC about their son's care. They raised concerns about the quality of information provided about his nut allergy, resulting reactions, and links between asthma and nut allergy. They were also concerned about the lack of planned follow-up or review when their son was discharged from paediatric overview. They felt that the confusion that arose could have been prevented if there were more formal links with an immunology service.

GP

The parents also had some concerns relating to the GP's care. These revolved around: the review system; the GP's role in reviewing/updating the management of a child's nut allergies; whether the allergy was taken into account when considering treatment for asthma; and whether the impact of deteriorating asthma on the allergy management/risk was considered.

Wider issues

His parents also raised some wider issues, such as that the health authorities did not provide national standards or consistent national delivery of advice and treatment on food allergies. They were concerned about the availability of immunology services and direct links between paediatricians and immunologists. They considered that advice on when to prescribe and administer adrenaline auto-injectors like EpiPens® was unclear and inconsistent across the country.

The paediatrician's response

The paediatrician indicated that he discussed the use of an EpiPen® with the mother in 2005. His view was that as the boy did not have a history of cashew anaphylaxis he did not need to carry an EpiPen®. Due to his change in response to cashews, he used the term "anaphylactoid" and considered that the boy needed prednisolone as well as Phenergan at that point. He advised that he discussed these options with the boy's mother and he considers that the management prescribed was consistent with relevant guidelines. The paediatrician said he commented "I would have a low threshold to giving [him] an EpiPen® if anyone felt he needed one (see ASCIA guidelines 'may be recommended')".[1]

The paediatrician said he explained to the boy's mother that an anaphylactic reaction is a severe life threatening reaction in which there is acute respiratory and/or cardiovascular compromise and "the term 'anaphylactoid' reaction is widely used … to describe a 'pseudoallergic' reaction which has some features of anaphylaxis but not the same consequences".

The paediatrician is unable to recall, but does not think he would have said that the boy's reaction would change to an anaphylaxis. He noted that, apart from the risk of anaphylaxis being remote, one of the reasons EpiPens® are not routinely given is that they have a shelf life of about a year, meaning regular renewal and expense. They are also light and temperature sensitive. In some cases, such as when there is significant ingestion of the antigen, there is no certainty that they will be of assistance.

The paediatrician also responded that he emphasised keeping the boy's asthma well controlled and he discussed asthma treatment such as inhaler technique to aid control. He recalls during the final consultation, in August 2007, asking about the allergy and that he was reassured that the boy had been kept off cashews and had no further reactions. At that stage, his asthma was well controlled.

The paediatrician outlined that his preference when discussing the seriousness of such conditions is to not specifically tell a parent that asthma or allergy could be fatal, which could cause unnecessary distress. He focuses on reinforcing the appropriate management of the conditions.

GP's response

The GP responded that after the boy was discharged by the paediatrician in August 2005, her GP role was to provide prescriptions, ensure the notes recorded the diagnosis, and reinforce any management plans instigated by the paediatrician. If any recurrent symptoms indicated a review of allergies was required then she would refer the patient back to the paediatrician.

The GP advised that her software review system does not automatically remind a clinician about allergy reviews. Any review required would need to be loaded manually into "Recalls". She said that she did not do this, because she was strongly guided by the paediatrician's letters of March and August 2005. The letters indicated to her that thorough discussions were had with the boy's mother about allergies, allergy reaction types, and treatment options. She considered that the letters reflected that a joint decision had been made about the boy continuing to use Phenergan and prednisolone.

The GP said that the deterioration in the boy's asthma appeared to her to be multi-factorial. She was not aware of there being any relationship between the severity of a nut allergy and worsening asthma. Any causal connection with a nut allergy she considered would be more within the sphere of a sub-specialist paediatrician.

Expert advice - key points

HDC requested preliminary expert advice from Dr Caroline Corkill, GP, and Dr Roger Tuck, General Paediatrician, in relation to the care provided by the paediatrician and the GP.

Dr Corkill remarked that the parents took their son to see doctors appropriately and that the GP appeared to monitor and treat his conditions appropriately.

Dr Corkill considered that the doctors caring for the boy had diagnosed his asthma and were treating it appropriately. Signs and symptoms were measured and recorded, and suitable medication was used to treat the asthma. Appropriate tests were requested and the notes record the GP was seeking specialist opinion appropriately. The notes showed reasonable care of his allergies and that the GP did well to identify the cashew allergy when he was a four-year-old. Dr Corkill commented that consideration of allergies is relevant when reviewing deteriorating asthma and that it may well be that such consideration is best given in the context of a paediatric or immunologic specialist review. She is not aware of any formal requirement or recommendation for monitoring of allergies, and that GPs in her peer review group do not routinely monitor or follow up patients regarding allergies unless requested or driven by the patient's problems. Dr Corkill also advised that she believes it is a shared responsibility of the patient/family, GP and specialist to follow up on any health problems.

Dr Tuck considered that the paediatrician's approach was consistent with that expected of a paediatrician in 2005 and he had provided an appropriate general paediatric consultation. Dr Tuck noted that cashew nut allergy was well recognised in 2005, and the high risk association with atopic asthma was first identified in the literature that year. The risk association has become increasingly apparent in recent times. Dr Tuck stated that the definition of anaphylaxis is now agreed internationally and the term "anaphylactoid" is discouraged, and that many reactions previously described as anaphylactoid are in fact IgE mediated and therefore anaphylactic.[2]

Dr Tuck also commented:

  • Food allergy is an emerging problem and GPs and general paediatricians are now much more widely educated than they were in 2005;
  • Educational material and web-based guidelines are more widely available;
  • Surveillance and management of long-term conditions should happen in a partnership of patients/parents, general practitioners, and specialists - involving provision of contemporary information and encouraging a personal interest in keeping up to date with trends;
  • The boy's long-term conditions should have been under ongoing review. Surveillance and management of this should happen in a partnership of patients/parents, GPs, and specialists;
  • Adrenaline delivery systems (like EpiPens®) are costly, which is an issue for those who are not well resourced. Families using such devices require support and education, which is variable around the country; and
  • International literature suggests that these devices are not always prescribed appropriately, are often not available to the patient when most needed and are not without serious side effects, including death, if inappropriately used.

Overall, the Commissioner was satisfied that the decisions made, and the care provided by the GP and the paediatrician was reasonable in the circumstances and at the time. However, the Commissioner was mindful of Dr Tuck's comment that the boy's long-term conditions, including his nut allergy, should have been under ongoing review. The Commissioner suggested to both the GP and the paediatrician that they reflect on Dr Tuck's comment in respect of their future practice, and keep abreast of ongoing developments in this field - including the issue of health professionals working more closely together, with families, to ensure quality and continuity of services and co-operative monitoring of long-term conditions.

Learning opportunities

There are ongoing developments in relation to food allergies in children. HDC's experts along with appropriate clinicians and professionals working in this field recently provided HDC with the following information:

  • Dedicated allergy clinics have been developed within some general paediatric services around New Zealand. However, currently there is only a specialist paediatric allergy/clinical immunology service situated at Starship Hospital, and no national service. Starship specialists undertake outreach clinics in allergy and clinical immunology in three DHBs (Bay of Plenty, Southland and Waikato), and accept referrals at Starship from paediatricians around New Zealand as needed;
  • Some DHBs employ clinical eczema/allergy nurse specialists. Nurse specialists often receive calls from families for assistance in managing their child's food allergies;
  • Many DHBs endeavour to increase awareness of managing allergies appropriately across the health sector by updating public health nurses on a yearly basis, networking with other nurses, and working with paediatricians to disseminate information to GPs via the medical website Healthpoint (www.healthpoint.co.nz) or via GP/paediatrician liaison;
  • Public health nurses are generally involved in school education about allergies and adrenaline devices, but generally not in preschools. However, in some areas, public health nurses are involved in both pre-school and school education;
  • Allergy NZ has been supported by ADHB to run a number of educational workshops for early childhood services concerning prevention, recognition and management of food allergic reactions. Allergy NZ also supports training for groups and services in some other centres in conjunction with volunteer health professionals;
  • The Paediatric Society of New Zealand, led by paediatric allergy and immunology specialists, has formed a special interest group (Allergy SIG) which has a paediatric representative from most DHBs to support the upskilling of paediatricians. The Allergy SIG is developing a draft consensus statement for diagnosis and management of food allergy in New Zealand children;
  • A New Zealand Clinical Immunology and Allergy Group (NZCIAG) comprises most of the immunologists, allergists, and clinical nurse specialists working in this area. NZCIAG has developed guidelines, which to date, have mainly been clinical immunology related, and are often used to review best care options for a range of rare and problematic conditions. Consideration of guidelines on other topics such as food allergy has been proposed;
  • The first ASCIA allergy action plans were released in 2003, along with the ASCIA guideline for EpiPen® prescription. This information was disseminated to paediatricians around New Zealand. Updates about new versions of the action plans have also been disseminated;
  • The ASCIA website (http://www.allergy.org.au) contains information on the recognition and management of allergies and anaphylaxis. In 2009, ASCIA started to develop online e-learning modules initially for schools and preschools, and subsequently for health professionals;
  • Allergy NZ have a booklet "Letting go" which helps families develop strategies for discussing risk assessment. ASCIA has published a document for use in schools and preschools[3];
  • The EpiPen® prescription guideline was developed in 2003, and it remains the general framework for recommendation of self-injectable adrenaline.
  • Since April 2011, AnaPen® has come on to the New Zealand market. The devices are currently unfunded by Pharmac;
  • Allergy NZ liaise with public health nurses who identify children enrolling at school who have been diagnosed by a general practitioner with a food allergy and advised to get on auto-injector however can not afford it, and/or do not have an action plan on treating anaphylaxis. Allergy NZ Guidelines state that children enrolling in school who have been advised to get an auto-injector should have an ASCIA anaphylaxis action plan signed by their doctor;
  • Allergy NZ is currently updating guidelines for schools to incorporate the Anapen® and the EpiPen2® which is due in New Zealand shortly; and have disseminated information on these new auto-injectors and their related Action Plans through its database of health professionals, including the public health nurses who work with families and schools. The Action Plans can also be downloaded from its website www.allergy.org.nz
  • Allergy New Zealand promotes the use of Action Plans through its communications relating to anaphylaxis. This includes: "Allergy & Anaphylaxis Guidelines for Early Childhood Services & Schools" (2006); a 2009 pamphlet on anaphylaxis; information on its website; and through its magazine "Allergy Today"; and
  • Best Practice Advocacy Centre (BPAC) NZ, Better Medicine, Issue 18, December 2008, includes the article The Management of Anaphylaxis in Primary Care featuring a section on long term management, education about avoiding triggers, and risk reduction. See: http://www.bpac.org.nz/magazine/2008/december/contents.asp

The boy's parents requested that this case study highlight the need for parents, as well as care providers, to keep abreast of developments and to seek regular review of their child's food allergy, given that medical research and knowledge, factual contexts, and risk factors can change over time.

Following discussion with the boy's parents, HDC formulated this case study to place on the HDC website for educational purposes, and brought the case to the attention of the Royal New Zealand College of General Practitioners (RNZCGP), the Paediatric Society, Coronial Services, the NZCIAG, the Ministry of Health, Pharmac, the National Health Board, and the Health Quality and Safety Commission.

 


[1]See the Australasian Society of Clinical Immunology and Allergy (ASCIA) website: http://www.allergy.org.au/anaphylaxis/epipen_guidelines.htm regarding guidelines for EpiPen® prescription in the context of an anaphylaxis management plan.

[2] Today the Australasian Society of Clinical Immunology and Allergy (ASCIA) defines anaphylaxis as a rapidly evolving generalised multi-system allergic reaction characterised by one or more symptoms or signs of respiratory and/or cardiovascular involvement and involvement of other systems such as the skin and/or the gastrointestinal tract.

[3] See Journal of Paediatrics & Child Health, December 2004, Volume 40, Issue 12, page 669-671.

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