Fatal delays in administering life-saving adrenaline autoinjector (EpiPen) for food anaphylaxis, a severe and rapid allergic reaction, is highlighted in research being presented at the Royal College of Emergency Medicine Conference today [28 April]. Researchers are urging for updated guidelines on the use of adrenaline treatment such as EpiPens and the hospital management of severe food anaphylaxis.

Fatal food anaphylaxis is rare but preventable. Hospital admissions for food allergies in children have increased by 600%² over the past two decades. In 2024, a Lancet study revealed that food allergy rates have doubled between 2008 and 2018, with an increase in childhood cases.

At this week’s conference, researchers from the University of Bristol and Bristol Children’s Hospital present findings from two Clinical & Experimental Allergy studies that examined data from the National Childhood Mortality Database (NCMD) on fatal food-induced anaphylaxis in children. The research identifies key interventions that could help prevent future tragedies.

The first study examined the factors that contributed to the tragic deaths of 19 children between 2019 and 2023 from fatal food-induced anaphylaxis. Key findings from both studies include:

• In 74% of cases, no adrenaline autoinjector (AAI), such as an EpiPen, or only a single dose was administered before cardiac arrest.
• 37% (7) of the 19 children did not carry an AAI, highlighting a major point of intervention and area for improvement concerning this potentially life-saving drug
• In 6 cases, the child or carers did not carry any AAIs, and in one case, only one AAI was available, preventing a second dose from being administered promptly.
• The average time from symptom onset to cardiac arrest was 14 minutes in the 12 cases where data was available highlighting the short window of time
• In all 19 cases, the child went into cardiac arrest before reaching an emergency department. Of these, 9 (47%) were 15 to 17 years, 8 (42%) were 10 to 14 years, and 2 (11%) were under 10 years.

Previous research on deaths from asthma and anaphylaxis found that most fatal cases were triggered by food and occurred in the home, public spaces, or schools, highlighting the need for improved pre-hospital management to prevent child deaths. Recent work also reveals that anaphylaxis triggered by different allergens affects bodily systems (airway, breathing, or circulation) in distinct patterns. Fatal food anaphylaxis is more strongly associated with airway and breathing compromise.

In a second Clinical & Experimental Allergy study, the same research team analysed the timeline of events of fatal food anaphylaxis to identify lessons for improving its hospital management.
An analysis of 17 cases, where the failed bodily system that led to death could be identified, revealed that in all but one case, lung failure was the primary cause of death. This finding is significant, as current NHS guidelines focus on heart and circulatory failure, suggesting that children who reach the hospital may not get the most effective emergency treatment they need, in the time they need it.
Dr Tom Roberts, NIHR Academic Clinical Lecturer in Emergency Medicine at Bristol Medical School at the University of Bristol and A&E clinician at North Bristol NHS Trust (NBT) and a co-author on the research, explained: "Anaphylaxis from a food allergy is a life-threatening emergency requiring immediate adrenaline. While EpiPens work quickly to reverse symptoms by reducing swelling and opening up airways.

“Our research reveals that in many cases, children did not receive enough adrenaline before cardiac arrest, and some didn’t carry an AAI at all. There is a very short window of time, often just minutes, in which appropriate treatment can potentially alter the clinical course of these events. Delays in delivering adrenaline treatment, which sometimes may require more than one dose, can have fatal consequences.”

Dr John Covney, the study’s lead author from Bristol Children’s Hospital, added: “Our research also found that airway and breathing problems were the most common causes of fatal food-related anaphylaxis in children. NHS guidelines currently focus on heart and circulatory failure in emergency management, our findings suggest that the focus should be on breathing issues, which were by far the most frequent cause of death in the cases we analysed. Circulatory problems without breathing issues were rare, indicating that updated guidelines should prioritise airway and breathing management in these critical situations."

Dr Ben McKenzie, an Emergency Medicine doctor from the University of Melbourne, and one of the lead authors on an Australian analysis also being presented, who also tragically lost his 15-year-old son to food anaphylaxis, said: “This UK research, confirms our Australian findings that fatal food anaphylaxis is driven by a closing of the airways in the lungs. We need to promote the chain of survival in anaphylaxis – get help, give adrenaline and for healthcare workers – get oxygen into the body as a priority. …”

Professor Karen Luyt, Programme Director for the National Child Mortality Database and Professor of Neonatal Medicine at the University of Bristol, added: “Every child’s death is a profound loss. By learning from every child death, we can identify where systems, services and support need to be improved to protect children’s lives.”