The Frequency of Food Allergens as Triggers of Severe Allergic Reactions

Data from the Anaphylaxis Registry

Anaphylaxis is an acute-onset, potentially life-threatening reaction (1). The number of anaphylaxis-related hospitalizations is steadily rising, as shown by data on emergency presentations (2). Children in particular are more frequently affected by food-related anaphylaxis (increase in hospital admissions from 0–4/100 000 in 2000 to 4–8/100 000 in 2015).

This article analyzes the frequency of foods triggering anaphylaxis.

Materials and methods

Since 2007, the Anaphylaxis Registry has been collecting data on age, sex, triggers, and other circumstances surrounding anaphylaxis via a standardized online questionnaire (3). Trained staff at the participating allergy centers enter the data once patients have undergone allergy testing. The data are annually subject to quality control with plausibility checks and a query process. Only cases that meet the criteria for anaphylaxis as defined by the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) (4) are considered. For the analysis presented here data obtained until March 31 2024 was considered.

Results

Current data from the Anaphylaxis Registry

A total of 18 496 case reports were registered up to March 2024. Of these, 92% (n = 16 988) met the criteria for anaphylaxis (4). Since 2011, approximately 1200 cases have been reported to the Anaphylaxis Registry every year.

In our dataset, insect venom, foods, and drugs are the most frequently reported triggers of anaphylaxis. These triggers have an age-related distribution: In children, foods are the most common triggers of a reaction (70%, 95% confidence interval: [69; 72]) followed by insect venom (16%, [15; 17]) and drugs (5.2%, [4,6; 5,9]), while in adults these are insect venom (50%, [49; 50]), medications (23%, [22; 23]), and foods (21%, [20; 21]).

An analysis of the data shows that the triggers of food-induced anaphylaxis have an age-dependent distribution: In children, they are most commonly peanut, followed by cow’s milk, cashew, hen’s egg, and hazelnut—in adults, they are crustaceans, molluscs, and wheat (Figure).

Figure

Frequent triggers of food-induced anaphylaxis in children and adults in whom the trigger has been confirmed by allergy testing

Food allergens are more likely to trigger recurrent anaphylaxis compared to other major triggers (medications, 19% [18; 21]; insect venom, 28% [27; 29]; and food, 40% [39; 41]). In terms of individual food, wheat and peanut are frequently reported to elicit recurrent reactions (Table).

Table

Frequency of recurrent reactions to selected triggers of food-induced anaphylaxis

Food-induced anaphylaxis can be severe and even fatal. Due to the structure of data collection in the Anaphylaxis Registry (reporting via allergy centers), only isolated cases of fatal reactions (n = 36) have been registered, but up to 348 very severe, near-fatal cases of anaphylaxis. While primarily medications (near-fatal: n = 142, 45%; fatal: n = 14, 50%) and insect venom (near-fatal: n = 132, 42%; fatal: n = 11, 39%) triggered the most severe cases of anaphylaxis in adults, food was the culprit in children (near-fatal: n = 16, 46%; fatal: n = 7, 88%).

Discussion

Common triggers of anaphylaxis are age-dependent. These are food allergens in children and insect venom in adults (3). In terms of foodstuffs, peanut, cow’s milk, cashew, hen’s egg, and hazelnut most frequently trigger anaphylaxis in children, while crustaceans, molluscs, and wheat are the main triggers in adults. The frequency of recurrent reactions to foods is high and allergen-dependent. The highest rate of recurrent reactions was found among adults with wheat allergy. Particularly in the case of IgE-mediated wheat allergy, it is important to identify cofactors, since reactions are more likely to be triggered in the presence of a cofactor such as physical exertion (5).

In summary, the data show that food allergens are frequent triggers of severe allergic reactions in childhood. The question of whether tolerance to the allergen in question develops over the course of life or whether adults avoid the allergen more effectively should be further investigated. The high rate of recurrent anaphylactic reactions in food allergies highlights the need for dietary counseling by healthcare professionals trained to deal with allergies. Furthermore, affected individuals should be prescribed an emergency first-aid kit, including an adrenaline auto-injector for self-medication (1).

Margitta Worm, Sabine Dölle-Bierke, Veronika Höfer

Allergology and Immunology, Department of Dermatology, Venerology and Allergology, Campus Mitte, Charité Berlin, Germany (Worm, Dölle-Bierke, Höfer), [e-mail]

Funding

The Anaphylaxis Registry is supported by the Network for Online Registration of Anaphylaxis NORA e.V.

Acknowledgments

We would like to thank all centers actively participating in the Anaphylaxis Registry (listed on www.anaphylaxie.net).

Conflict of interest statement
MW has received consultancy fees and speaker’s honoraria as well as reimbursement of travel expenses and congress fees from Novartis, Sanofi-Aventis, DBV Technologies S.A., Aimmune Therapeutics, Regeneron Pharmaceuticals, Leo Pharma, Boehringer Ingelheim, ALK-Abelló Arzneimittel, Lilly, Kymab, Amgen, Abbvie, Pfizer, Mylan, AstraZeneca, and GlaxoSmithKline. SDB has received speaker’s honoraria from ALK-Abelló Arzneimittel and the DAAB. VH states that no conflict of interest exists.

Manuscript received on 8 August 2023, revised version accepted on 16 May 2024.

Translated from the original German by Christine Rye.

Cite this as:
Worm M, Dölle-Bierke S, Höfer V: The frequency of food allergens as triggers of severe allergic reactions—data from the Anaphylaxis Registry. Dtsch Arztebl Int 2024; 121: 610–11. DOI: 10.3238/arztebl.m2024.0110

References

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