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					                  Management of young boy with cashew nut allergy
                         (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.

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

17 January 2012                                                                               1

Names have been removed (except the experts who advised on this case) to protect privacy.
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

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

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;

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Names have been removed (except the experts who advised on this case) to protect privacy.
and whether the impact of deteriorating asthma on the allergy management/risk was

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

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

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

 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.

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Names have been removed (except the experts who advised on this case) to protect privacy.
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

 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

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Names have been removed (except the experts who advised on this case) to protect privacy.
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
        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

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

respiratory and/or cardiovascular involvement and involvement of other systems such as the skin and/or the
gastrointestinal tract.

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Names have been removed (except the experts who advised on this case) to protect privacy.
           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
           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

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

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Names have been removed (except the experts who advised on this case) to protect privacy.
        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.

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Names have been removed (except the experts who advised on this case) to protect privacy.

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