Coping with Life-Threatening Food Allergies

 Posted by on 23 September 2013 at 10:00 am  Food, Health, Medicine
Sep 232013

On Wednesday — the 25th — I’ll interview food allergy mom Jenn Casey about living well despite life-threatening food allergies. Unfortunately, the topic has been in the news of late, due to the death of Natalie Giorgi.

Here’s what happen to Natalie, as told by her parents:

Natalie Giorgi died July 26 after eating a Rice Krispie treat that had been prepared with peanut products at Camp Sacramento on the final day of a multi-family camping trip, her parents said. Giorgi had a documented allergy to peanuts.

“We had been there before. We had eaten their Rice Krispie treats before. We had never had a problem before,” Louis Giorgi said.

Giorgi said immediately after taking one bite of the treat, his daughter told her parents. She had been dancing with friends when she took the bite. “We gave her Benadryl like we’d been told,” Natalie’s father said.

Over the next several minutes, the Giorgis said their daughter showed no signs of a reaction whatsoever. “I kept asking, ‘are you OK?’ She kept telling me she was fine, and she wanted to go back to dancing with her friends,” Natalie’s mom said. Natalie kept asking her parents to go back to her friends, but they kept telling her she had to stay with them, to make sure she was OK.

“Then suddenly, she started vomiting,” Louis said. “It spiraled downhill out of control so quickly.” Natalie’s father, a physician, administered both of the EPI-Pens — used to slow or stop an allergic reaction — that the family carried with them. A third was obtained from the camp and administered. None of them stopped her reaction. Her dad called 911.

“I did everything right, in my opinion. I couldn’t save her,” Louis Giorgi said. Emergency responders who arrived later couldn’t save her, either.

“She had been fine, and had been talking to us. This was a worst-case scenario. One of the last things she said was, ‘I’m sorry, mom,’” Natalie’s mother said as she wiped a tear away from her cheek.

It’s a heartbreaking story, particularly because neither Natalie nor her parents were in any way irresponsible about their daughter’s food allergy.

Natalie’s death has raised a new round of questions about when epi-pens should be administered — after the ingestion of the known allergen or when symptoms appear. Natalie’s parents followed the latter protocol (which many doctors endorse) but that was too late.

On that question, this “Ask the Expert” Column from the American Academy of Allergy, Asthma, and Immunology was very informative. Here’s a bit:

These cases [of death due to ingestion of an allergen] illustrate a very important point. That is, the mean time to respiratory or cardiovascular arrest after the ingestion of a food to which a patient is allergic is 30 minutes (Pumphrey RS, Clinical and Experimental Allergy 2000; 30(8):1144-1150). Thus there is very little time for one to act after patients express even the mildest symptom of an anaphylactic event.

Nonetheless, we have all seen children (and adults) who experience initial symptoms such as itching of the back of the throat or nausea after eating a food, and who recover spontaneously. In the practice of Allergy, we do food allergen challenges on a regular basis and observe these spontaneous recoveries. Thus we are all prejudiced by these observations. These personal anecdotal observations have resulted in the debate as framed in this quote from the Journal of allergy and Clinical Immunology:

“Although there is little debate about using epinephrine to treat a SCIT SR” (meaning anaphylactic reactions to injection of an allergen), “there is a lack of consensus about when it should be first used.”

This debate has certainly extended to anaphylactic reactions to foods. The issue is not whether epinephrine is the drug of choice. Clearly it is. Other agents such as antihistamines do not act in time to prevent fatalities. Thus if we are going to prevent a fatality, the only tool we have to do so is epinephrine.

So what should be done? (Mind you, even if you don’t have food allergies, you might need to give someone advice on this matter at some point — and you could save their life!)

As the article says: “In July 2008, the World Allergy Organization published the following statements:”

Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses.

Again, I hope that you join Jenn and me on Wednesday for our discussion of living well with food allergies. We won’t just be focused on the person who has the food allergy: we’ll talk quite a bit about what friends and family can (and should) do to keep that person safe, without driving anyone crazy.

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