Kate Johnson

March 08, 2013

SAN ANTONIO, Texas — Roughly 11% of allergic reactions in children with known food allergies are the result of caregivers intentionally exposing the child to the allergen, according to a new study.

"Everybody calls these accidental ingestions...but as we started going through them, it was clear that these exposures were not all accidental," lead investigator Kim Mudd, RN, from Johns Hopkins University in Baltimore, Maryland, told Medscape Medical News.

The findings, presented here at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2013 Annual Meeting, are a surprising and disturbing revelation, Mudd said.

In a subanalysis of the observational Consortium of Food Allergy Research (CoFAR) study, Mudd, who is CoFAR research nurse and program coordinator, and colleagues examined 1170 allergic reactions reported by 512 families over a 36-month period.

Most reactions (n = 834) were to milk, egg, or peanut, and more than half of the families reported multiple reactions during the study period.

After examining detailed information about the circumstances of all allergic reactions, including how and where the exposure occurred, the type of reaction it triggered, and how it was treated, the researchers concluded that 11.2% of exposures were "purposeful," Mudd reported.

"It is clear that these exposures were not all the kid picking something off the floor or his cousin handing it to him," she said.

"Surprising and Disturbing"

Using these data and other purposeful exposures identified in a retrospective review, the researchers developed a questionnaire designed to probe the motivational issues connected to purposeful exposures. With it, identified 40 families with 52 purposeful exposures.

They determined that the allergen had been purposefully fed to the child by mothers in 64% of cases, by fathers in 21%, by grandmothers in 14%, and by other caregivers in 2%.

When asked the reason for intentionally exposing the child to the allergen, most respondents explained that they thought a small amount would be safe, Mudd reported.

Almost one third of respondents said the child had not reacted to the allergen after a previous exposure, 25% said they thought the exposure would help resolve the allergy, and 24% said the child's previous reaction to the allergen had not been severe in their opinion.

Table. Reasons for Exposing Children to Allergens

Explanation Caregivers (%)
Thought a small amount would be safe 46
Wanted to see if the allergy had resolved 42
Child had tolerated a baked form of egg or milk, so thought it would be safe 38
Child had not reacted to the allergen after a previous exposure 29
Thought the exposure would help resolve the allergy 25
In their opinion, thought the child's previous reaction to the allergen had not been severe 24
Did not think the child's diagnosis was accurate 15
Believed that a decrease in the child's immunoglobulin E meant a resolution of the allergy 14
Wanted to test the severity of the allergic reaction 8
Had read an article that influenced their decision to try an at-home exposure 4
Child was scheduled for an in-office oral food challenge so they decided to try it first at home 2


"We need to keep telling these people that reactions can occur despite low or improving immunoglobulin [Ig]E measurements, that eating small amounts can trigger a reaction, that tolerance to baked milk or baked egg does not indicate tolerance to unheated milk or egg, that any concerns about the diagnosis being incorrect should be discussed with the allergist, and that it is unsafe to try foods at home, even in small amounts," Mudd emphasized.

However, "even if you do a fantastic job at education, education isn't all of it. Telling people how to avoid, how to not cross-contaminate, that they need to read the label — all of it is not enough, but what else do we have?" she added.

At the root of many purposeful exposures is a sense of frustration and impatience, Mudd acknowledged. "They want to have their kids' and their lives as normalized as possible."

She told Medscape Medical News that "I know within my population who is going to do this," she said. "I have one dad who's tried this multiple times. I've told him, 'I understand your frustration, I know you don't want your child to be milk-allergic, and I promise if we get any indication he is ready, I will do a safe oral challenge, under observation in the office. But the kid's IgE is still in the stratosphere, so stop giving him Cheezos!' "

High-Risk Situation

During the question period at the meeting, Stephen McGeady, MD, from Thomas Jefferson University in Philadelphia, Pennsylvania, said "I think your bias is there's a lot more people doing it."

Mudd conceded that the findings probably represent just the tip of the iceberg, and that many intentional exposures likely going unreported.

"We probably missed some of the mild cases," she acknowledged. "These are the ones where the family reported measurable symptoms like change in skin, respiratory issues, and vomiting."

Dr. McGeady told Medscape Medical News that he suspects that many of the survey respondents were not honest. "I think there are probably a lot more people who have done this than are owning up," he said. "I have a very comparable practice to what they're reporting. We see a lot of food allergy, but when I hear things like 'his little brother gave it to him,' or 'I turned my back for just a second,' I sometimes think those are people who intentionally did it."

Dr. McGeady said that the spectrum of reasons reported in the study seems consistent with his experience, and added that this underscores the importance of frank discussion with families.

We never advocate doing oral challenges at home.

"There aren't a lot of deaths reported from food allergy reaction, but virtually 100% of them are in asthmatic individuals, so we spend a lot of time emphasizing that this is serious," he explained.

"We always prescribe EpiPens if the child is both food allergic and asthmatic, or if the child is tree nut, peanut, or seafood allergic. I think that probably should send a message that your doctor thinks this could be life-threatening," Dr. McGeady noted.

Stuart Abramson, MD, head of the AAAAI scientific program committee and staff allergist and immunologist at Shannon Medical Center in San Angelo, Texas, was asked by Medscape Medical News to comment on the findings. "We never advocate doing oral challenges at home. Even if kids might have had some accidental ingestion that they tolerated, oral challenges can only be done safety in a physician's office. There's not, at this point, a safe way to challenge someone who's had a serious food reaction without getting a physician's input," he said.

This study is funded by the National Institutes of Health. Ms. Mudd, Dr. McGeady, and Dr. Abramson have disclosed no relevant financial relationships. Scott Sicherer, MD, senior investigator on the study, reports being a consultant for the Food Allergy Initiative and Novartis, being a medical advisor for Food Allergy Research & Education, and receiving royalties from UpToDate.

American Academy of Allergy, Asthma & Immunology (AAAAI) 2013 Annual Meeting: Abstract 451. Presented February 24, 2013.